Citation Nr: 21072082
Decision Date: 12/02/21	Archive Date: 12/02/21

DOCKET NO. 17-32 142
DATE: December 2, 2021

ORDER

Entitlement to service connection for diverticulitis is granted.

Entitlement to a 70 percent rating for posttraumatic stress disorder (PTSD), as of August 23, 2019, is granted.

Entitlement to a rating in excess of 70 percent for the period following August 23, 2019, is denied.

Entitlement to an initial 10 percent evaluation for opioid-related constipation is granted.

REMANDED

Entitlement to service connection for a gastrointestinal disability, claimed as acid reflux, to include as secondary to service-connected disability is remanded.

Entitlement to service connection for hypertension to include as secondary to service-connected disability is remanded.

FINDINGS OF FACT

1. The Veteran's diverticulitis was caused or aggravated by medication used to treat his service-connected lumbar spine disability. 

2. As of August 23, 2019, the Veteran's PTSD was manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgement, thinking or mood.

3. For the period following August 23, 2019, there is no evidence that the Veteran's PTSD was manifested by total social and occupational impairment.

4. The Veteran's opiod-related constipation is manifested by periods of frequent constipation, loose stools, abdominal pain, and alternating diarrhea and constipation.

CONCLUSIONS OF LAW

1. The criteria for service connection for diverticulitis have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310(b).

2. The criteria for a 70 percent rating for PTSD, as of August 23, 2019, have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.16, 4.130, Diagnostic Code (DC) 9411.

3. The criteria for a rating in excess of 70 percent for PTSD for the period following August 23, 2019, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.16, 4.130, Diagnostic Code (DC) 9411.

4. The criteria for an initial 10 percent evaluation for opioid-related constipation have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 3.102, 4.114, Diagnostic Code 7319.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from November 1992 to November 1996. 

These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO).

1. Entitlement to service connection for diverticulitis

The Veteran has contended that he suffers from diverticulitis, which is related to his service-connected opioid-related constipation. See Statement in Support of Claim, submitted June 20, 2017.

Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).

As an initial matter, when the Veteran's claim for an increased rating for opiod-related constipation was before the Board in March 2019, it was remanded to obtain a VA examination and medical opinion. As part of the opinion, the examiner was instructed to determine whether the Veteran's diverticulitis was within the scope of his service-connected opiod-related constipation, or should be considered a separate and distinct disability. In a November 2019 VA medical opinion, the examiner determined that diverticulitis was a separate and distinct disability, as it is a complication within the lower intestinal tract.

Having determined that the Veteran's claimed diverticulitis is a separate and distinct disability, the Board can move on to the question of whether service connection is warranted for the condition.  

With regard to whether the Veteran has a current diagnosis of diverticulitis, there is evidence weighing both for and against his claim. The Veteran's VA treatment records, as recently as 2019, indicate that he has a history of diverticulitis. Additionally, the November 2019 VA examiner indicated that the Veteran was diagnosed with the condition in 2015. Adversely, the examiner also noted that the Veteran's diverticulitis had not reoccurred in some years.

For the purposes of establishing service connection, the evidence need only show that the Veteran had a current diagnosis of the claimed condition during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The evidence raising the possibility that the Veteran's diverticulitis may be caused or aggravated by a service connected disability was submitted in June 2017. As noted above the Veteran's VA treatment records show a history of diverticulitis as recently as 2019. Thus, the Board resolves all doubt in favor of the Veteran and concludes that he has a current diagnosis of diverticulitis.

The remaining question is whether the Veteran's diverticulitis was proximately caused or aggravated by a service-connected disability, or in this case, medication used to treat a service-connected disability. The medical evidence of record shows that the Veteran has a history of treating his service-connected lumbar spine disability with opioid medications. As noted above, the Veteran is also service-connected for opiod-related constipation. 

The November 2019 examiner opined that it was at least as likely as not that the opioid medication contributed to or caused the Veteran's diverticulitis. As rationale, the examiner stated that medical literature showed that long term opioid use was a known risk factor for diverticulitis. 

The Board finds the November 2019 examiner's opinion is highly probative, as it is based on an accurate medical history, considers relevant medical literature, and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

Based on the foregoing, the evidence establishes that the Veteran has a current diagnosis of diverticulitis that was caused or aggravated by the use of opioid medication to treat his service-connected lumbar spine disability. Accordingly, service connection is warranted for diverticulitis.

INCREASED RATINGS

Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The Schedule is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When two evaluations are potentially applicable, VA will assign the higher evaluation when the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. VA will resolve reasonable doubt as to the degree of disability in favor of the Veteran. 38 C.F.R. § 4.1. If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. 

In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). As a result, a complete medical history of the Veteran is required for a ratings evaluation. This is in order to protect claimants against adverse decisions based on a single, incomplete, or inaccurate report, and to enable VA to make a more precise evaluation. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, VA has a duty to acknowledge and consider all regulations which are potentially applicable, and to explain the reasons and bases for its conclusions. 

1. Entitlement to an initial 70 percent rating for posttraumatic stress disorder (PTSD)

2. Entitlement to a rating in excess of 70 percent for PTSD for the period following November 19, 2019

In an April 2016 rating decision, the Veteran was awarded service connection for PTSD, evaluated as 50 percent disabling, effective December 10, 2015. He filed a Notice of Disagreement in April 2017, contending that his symptoms were more disabling than currently rated. During the pendency of the appeal, an April 2020 rating decision increased the Veteran's PTSD from 50 percent disabling to 70 percent, effective November 19, 2019 (date VA examination showed worsening of the condition). The Veteran contends that a higher initial rating is warranted for his service-connected PTSD. 

The Veteran's PTSD is evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411.

Under this criteria, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., the retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships.

A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgement, thinking or mood, due to symptoms such as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); or an inability to establish and maintain effective relationships.

Finally, a maximum of 100 percent rating is warranted for total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name.

Symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). When determining the appropriate disability evaluation to assign, the Board must make findings as to how the Veteran's symptoms impact his or her occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). All ratings in the general rating formula are associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms; a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118.

Turning to the evidence of record, the Veteran was afforded a VA examination in March 2016. He reported that he didn't have much of a relationship with his brother or sister, but that his relationship with his mother was "ok". He reported having friends, but not having much contact with them. He also reported being divorced and having 3 children. At the time, the Veteran had been employed at the Department of Labor for 5 years and previously at the Department of Corrections for 11 years.

For VA rating purposes, the Veteran's symptoms were noted as anxiety, chronic sleep impairment, circumstantial, circumlocutory, or stereotyped speech, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner indicated that the Veterans PTSD was moderately severe in intensity and was manifested by occupational and social impairment with reduced reliability and productivity.

He was also afforded a VA examination in May 2017. The Veteran reported living with his significant other and his children, but that the relationship with his significant other was "rocky". He reported that his relationship with his children was "okay". He reported that his hobbies included going to his children's sporting events and spending time with his family. He remained working for the Department of Labor and denied any significant occupational impairment.

For VA rating purposes, the Veteran's symptoms were noted as anxiety, suspiciousness, and chronic sleep impairment. The examiner that the Veteran was dressed neatly and was well kempt, and that his speech was logical and goal-oriented. He was oriented to person, place, situation, and time, his concentration and attention were noted as good, and his judgment and insight were good. The Veteran described his mood as "crabby", and his affect was calm. The examiner noted that it appeared the Veteran's symptoms have improved since his last evaluation as he has not required any mental health treatment. The examiner concluded that the Veteran's PTSD was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.

The Veteran submitted a statement in June 2017. He reported his symptoms as follows: anger, anxiety, chronic sleep problems, denial, depression, difficulty making decisions, emotional numbing, flashbacks, guilt, hallucinations, heavy use of alcohol, inability to make and keep friends, intrusive thoughts, isolation, lack of emotions, lack of self-esteem, memory loss, neglect of personal hygiene, neglects family, no friends, panic attacks, problems with communication, problems at work, problems getting along with people, suspiciousness, and unable to share feelings. See Statement in Support of Claim, submitted June 21, 2017.

The Veteran's VA treatment records contain an August 2019 pain consult that addresses his PTSD. The Veteran was noted to have symptoms of sleep impairment, irritability, angry outbursts, anxiety, and poor short term memory. There was no evidence of hallucinations observed or reported, and no history of suicidal ideation. He was noted to have adequate grooming, normal speech and thought content, an irritable mood, and congruent affect. He denied a history of treatment for PTSD. His PTSD was noted to be severe. See CAPRI, records submitted November 11, 2019 (Record dated August 23, 2019).

The Veteran was again afforded a VA examination in November 2019. He reported that he spends the majority of his time working and engaging in familial obligations. He reported social isolation and having only acquaintances. He remained employed at the same job, but reported being frustrated with his work environment. He reported sleep impairment and periods of irritability and inattention.

For VA rating purposes, the Veteran's symptoms were noted as anxiety, suspiciousness, depressed mood, chronic sleep impairment, flattened affect, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, and inability to establish and maintain effective relationships. He was noted to be dressed neatly, with logical and goal oriented speech. He was oriented to person, place, situation, and time. The examiner noted that his concentration, attention, judgment, and insight were good. The Veteran described his mood as nervous and anxious, and he was noted to have a flattened affect. The examiner noted that the Veteran's symptoms did not seem to have worsened since his March 2016 evaluation. The examiner concluded that the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity.

In this case, resolving all doubt in favor of the Veteran, the earliest date that it is factually ascertainable that a worsening of the Veteran's PTSD occurred is August 23, 2019. The VA treatment record from this date indicates that the Veteran's PTSD was noted to be severe. This is compared to the March 2016 examination when the Veteran's PTSD was noted to be moderately severe and the May 2017 examination, wherein the examiner indicated that it appeared the Veteran's symptoms had improved since his last evaluation.  

The Veteran's attorney contends that the Veteran has been endorsing a worsening of his symptoms since 2017. While the Board does not disagree that the Veteran has been pursuing a higher initial rating for PTSD since the filing of his April 2017 Notice of Disagreement, the medical evidence of record simply does not support a 70 percent rating prior to August 23, 2019. Notably, neither the March 2016 nor May 2017 examiner opined that the Veteran's PTSD was manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgement, thinking or mood. Instead, the March 2016 examination showed that the Veteran's PTSD met the criteria for a 50 percent rating, and the May 2017 examination showed severity meeting the criteria for a 30 percent evaluation. Additionally, the Veteran did not report, and neither did the medical evidence show, many of the listed criteria for a 70 percent rating, to include: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); or spatial disorientation. Further, the Veteran himself did not report any occupational impairment at the time of the March 2016 and May 2017 examinations.

In weighing the evidence for this period, the Veteran's June 2017 correspondence relating to his PTSD symptoms also has not been overlooked. However, the report of symptoms at the time of the June 2017 correspondence seems inconsistent with the remainder of the evidence of record. Specifically, no other evidence of record to include all VA examinations conducted, shows symptoms of neglect of personal hygiene, panic attacks, or hallucinations. Adversely, the Veteran has consistently denied hallucinations, he was consistently noted to appear adequately groomed and well-kempt, and panic attacks were not reported at the time of any VA examination of record. Likewise, the Veteran did not report any occupational impairment at the time of the March 2016 and May 2017 examinations, but went on to endorse problems at work in the June 2017 correspondence. Given the inconsistencies with the remainder of the medical and lay evidence, the Board assigns higher probative value to the VA examinations of record.

The Board has also considered whether a rating in excess of 70 percent is warranted for the period following August 23, 3019, but finds that it is not. The next higher, 100 percent rating criteria contemplate total social and occupational impairment, which the Board finds is not shown in this case. The medical evidence of record does not show that the Veteran's PTSD has been manifested by persistent delusions or hallucinations, grossly inappropriate behavior, or a persistent danger of hurting himself or others. Additionally, the objective medical evidence has not shown the Veteran's inability to perform activities of daily living. Further, there is no evidence of disorientation to time or place, or memory loss for names of close relatives, his own occupation, or his own name.

Based on the above, the Board finds that the evidence supports a 70 percent rating as of August 23, 2019, and a rating in excess of 70 percent is not warranted for the period thereafter.

3. Entitlement to a compensable initial evaluation for opioid-related constipation

The Veteran was granted service connection for opioid-related constipation in a May 2017 rating decision, evaluated as noncompensable, effective December 10, 2015. He contends that an initial compensable rating is warranted.

The Veteran's noncompensable rating was awarded as analogous to irritable colon syndrome under the provisions of 38 C.F.R. § 4.114, Diagnostic Code 7399-7319. Diagnostic Code 7319 provides for a zero, noncompensable rating for mild symptoms with disturbances of bowel function with occasional episodes of abdominal distress, a 10 percent rating for moderate symptoms with frequent episodes of bowel disturbance with abdominal distress, and a 30 percent rating for severe symptoms of diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319.

At the time of the Veteran's December 2015 claim, he reported frequent diarrhea and stomach issues.

The Veteran was afforded a VA examination in April 2016 to assess his intestinal conditions. The examiner confirmed a diagnosis of opioid-related constipation that was resolved. The Veteran reported that he had developed chronic constipation while on pain medications for his service-connected lumbar spine disability, but that he had subsequently underwent a cholecystectomy for an unrelated condition and his constipation resolved following the surgery. He reported that he currently had regular bowel movements with no constipation issues. As the Veteran reported the condition had resolved, the examination was negative for any related signs or symptoms.

An April 2016 VA treatment record shows the Veteran's reports of abdominal pain and constipation for 2 days. The treatment record also noted the presence of loose stools. See CAPRI, submitted April 18, 2017 (record dated April 20, 2016.)

The Veteran was again afforded a VA examination in April 2017. The examiner confirmed a diagnosis of constipation dating back to 1998. The Veteran reported a similar history of constipation as previously described, and then having his gallbladder removed. He reported currently having days of constipation with an occasional loose stool after eating a fatty meal. He also reported that he would go several days without a bowel movement. He denied any continuous medication for the condition or surgical treatment. The Veteran's signs and symptoms were noted as alternating diarrhea and constipation. He was not noted to have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition. There was no evidence of weight loss, malnutrition, serious complications or other general health effects, or neoplasms or tumors. As to functional impact, the Veteran reported discomfort from constipation, and bloating and pressure which affects his ability to concentrate. 

The Veteran submitted a statement in June 2017, wherein he reported being constipated "all the time", with abdominal distress including pain and cramping. See Statement in Support of Claim, submitted June 20, 2017.

The Veteran was again afforded a VA examination in November 2019. The examiner indicated that there was no evidence of a current diagnosis of constipation. The examiner noted the Veteran's reports of always having constipation until having his gallbladder removed. The Veteran also reported having loss stools, but that his constipation resolved years prior. Outside of the daily loose stools, the examination report is silent for any other signs or symptoms.

In this case, the Board finds that, resolving all doubt in favor of the Veteran, the evidence supports a 10 percent rating under Diagnostic Code 7319. The lay and medical evidence, while sometimes conflicting, shows periods of frequent constipation, loose stools, abdominal pain, and alternating diarrhea and constipation. The evidence, however, does not show severe symptoms of diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress to warrant an increased 30 percent rating. While the Veteran reported frequent periods of constipation and loose stools, he also reported on several occasions that the condition had completely resolved. Additionally, none of the lay nor medical evidence shows that the Veteran's condition was manifested by more or less constant abdominal distress.

For the reasons stated above, an initial 10 percent rating is warranted for the Veteran's opioid-related constipation.

REASONS FOR REMAND

1. Entitlement to service connection for a gastrointestinal disability, claimed as acid reflux, to include as secondary to service-connected disability is remanded.

2. Entitlement to service connection for hypertension to include as secondary to service-connected disability is remanded.

When this matter was last before the Board in March 2019, it was remanded to obtain VA examinations and medical opinions to determine whether the Veteran's hypertension and any diagnosed gastrointestinal disability were caused or aggravated by a service-connected disability.

The Veteran was afforded a VA examination in November 2019. The examiner opined that neither condition was caused or aggravated by a service-connected disability. In determining that the conditions were not aggravated, the examiner stated that with so many intertwined and inseparable medical comorbidities, it was unknown and could not be stated whether the Veteran's hypertension and gastrointestinal conditions were "truly aggravated" beyond normal progression by his service-connected conditions.

In this case, the Board finds that the November 2019 examiner applied an incorrect standard of proof in rendering the secondary medical opinion. To establish service connection on a secondary basis, the evidence need only show that it is at least as likely as not (50 percent or better probability) that the conditions were caused or aggravated by a service-connected disability. Accordingly, remand is necessary to obtain an addendum medical opinion.

 Additionally, obesity can be an "intermediate step" between a service-connected disability and a current disability for secondary service connection purposes. See 38 C.F.R. § 3.310. To succeed on this claim, it must be shown that: (i) a service-connected disability caused him to become obese; (ii) obesity was a substantial factor in causing the secondary disability; and, (iii) the secondary disability would not have occurred but for the obesity. VAOPGCPREC 1-2017 (January 6, 2017). 

At the time of the November 2019 medical opinion, the examiner stated that there were several recognized risk factors for acid reflux, including weight. The examiner also indicated that the Veteran had risk factors for hypertension, including cholesterolemia. To that extent, the Veteran's VA treatment records show notations of a history of obesity, evidenced by a BMI above 30. Accordingly, the examination obtained on remand should also address whether the Veteran's obesity/being overweight is an "intermediate step" between any or all of the Veteran's service-connected disabilities and his claimed hypertension and gastrointestinal disability/acid reflux.

The matters are REMANDED for the following action:

Obtain a supplemental opinion from a VA examiner regarding the Veteran's hypertension and gastrointestinal disability/acid reflux. Make the Veteran's electronic claims file available to and ensure that it is reviewed by the examiner. All pertinent symptomatology and findings must be reported. The examiner should then provide the following opinions:

a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was caused by a service-connected disability, especially, but not limited to, PTSD, or any medication prescribed to treat a service-connected disability.

b.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was aggravated (worsened beyond normal progression) by a service-connected disability, especially, but not limited to, PTSD, or any medication prescribed to treat a service-connected disability.

c.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's gastrointestinal disability/acid reflux was caused by a service-connected disability, especially, but not limited to, PTSD, or any medication prescribed to treat a service-connected disability.

d.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's gastrointestinal disability/acid reflux was aggravated (worsened beyond normal progression) by a service-connected disability, especially, but not limited to, PTSD, or any medication prescribed to treat a service-connected disability.

The examiner is reminded that causation and aggravation are separate inquiries, and therefore, separate findings and rationales should be provided for each one.

e.) Whether it is it at least as likely as not (50 percent or greater probability) that any or all of the Veteran's service-connected disabilities (including any medications taken for the service-connected disabilities) caused or aggravated the Veteran's obesity/being overweight including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue.

f.) If yes, is it at least as likely as not (a 50 percent or greater probability) that the obesity/being overweight caused or aggravated the Veteran's hypertension and gastrointestinal disability/acid reflux, including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue.

The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation.

 

 

MARJORIE A. AUER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Marsh II, Associate Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.