Citation Nr: 21072235 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 19-30 268 DATE: December 2, 2021 ORDER Entitlement to an effective date prior to July 2, 2018 for the award of service connection for an adjustment disorder with depressed mood and insomnia (hereinafter "adjustment disorder") is denied. Reopening of the claim for service connection for joint pain is granted, the appeal is granted to this extent only. REMANDED Entitlement to an increased rating in excess of 30 percent prior to July 15, 2015 and in excess of 60 percent thereafter for psoriasis is remanded. Entitlement to service connection for headaches with dizziness, to include as secondary to psoriasis, is remanded. Entitlement to service connection for a cervical spine disability, to include as secondary to psoriasis, is remanded. Entitlement to service connection for a low back disability, to include as secondary to psoriasis, is remanded. Entitlement to service connection for joint pain, to include as secondary to psoriasis, is remanded. FINDINGS OF FACT 1. A September 2010 rating decision denied entitlement to service connection for stress as secondary to psoriasis. The Veteran was notified of his rights but did not appeal or submit new and material evidence during the applicable one-year appellate period. 2. On July 2, 2018, VA received an intent to file form, and on July 3, 2018 VA received a formal claim for service connection for posttraumatic stress disorder (PTSD), service connection for an adjustment disorder as secondary to psoriasis, and to reopen a claim for service connection for stress. 3. Between the September 2010 rating decision and the July 2, 2018 formal claim, there were no pending requests for service connection for an adjustment disorder or requests to reopen a previously denied claim for service connection for an adjustment disorder that remained unadjudicated. CONCLUSION OF LAW The criteria for an effective date prior to July 2, 2018 for the award of service connection for an adjustment disorder have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.114, 3.155, 3.156, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from July 1987 to July 1990. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in August 2015 and January 2019 by a Department of Veterans Affairs (VA) Regional Office (RO). By way of background, in August 2015 the RO granted service connection for psoriasis and assigned a 30 percent rating prior to July 15, 2015 and a 60 percent rating thereafter. The RO also denied entitlement to service connection for headaches, a cervical spine disability, and a low back disability, and denied reopening of a claim for service connection for joint pain. In July 2016, the Veteran filed a notice of disagreement with rating assigned for psoriasis, and the denials of service connection and reopening. A statement of the case was issued in December 2018, and the Veteran perfected an appeal in January 2019. Concerning the issue of entitlement to service connection for headaches, the Board notes that the claim was previously finally denied in a November 1995 rating decision. 38 C.F.R. §§ 20.302, 20.1103. However, that rating specifically noted that the Veteran's service treatment records were not associated with the file at the time. Since the issuance of the decision, the Veteran's service treatment records have been associated with the file, and reflect some treatment for headaches in service. As new, relevant service department records have been associated with the file since the prior denial, de novo review of the claim for service connection for headaches is warranted. 38 C.F.R. § 3.156(c). As such, the Board need not discuss the issue of new and material evidence with respect to the claim for service connection for headaches. During the course of the above appeal, in January 2019 the RO granted service connection for an adjustment disorder as secondary to psoriasis effective July 2, 2018, and the Veteran appealed the assigned effective date to the Board. In a September 2020 decision, the Board denied entitlement to an effective date prior to July 2, 2018 for the award of service connection for an adjustment disorder, and the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). A July 2021 Court Order implemented a Joint Motion for Partial Remand vacating the Board's denial of entitlement to an earlier effective date for the award of service connection for an adjustment disorder. The Veteran and his representative were notified that month that his appeal had been returned to the Board, and that they had a period of 90 days to submit additional evidence or argument. Clark v. O'Rourke, 30 Vet. App. 92, 9799 (2018). The 90-day period having elapsed, the Board will proceed to address the appeal on the merits. In September 2020 the Board also granted an increased rating of 70 percent, but no higher, for the Veteran's adjustment disorder and denied reopening of a claim for service connection for bilateral hearing loss. The Joint Motion for Partial Remand reflects that the Veteran abandoned his appeals of the denial of reopening and the denial of a rating in excess of 70 percent for an adjustment disorder, and therefore these issues are no longer before the Board. 38 C.F.R. § 20.1100. The Board also granted entitlement to a total disability rating based on individual unemployability and reopening of a claim for service connection for sleep apnea. As these awards constitute full grants of the benefits sought as to those issues, those claims are no longer on appeal. Ab v. Brown, 6 Vet. App. 35 (1993). Finally, in September 2020 the Board also remanded the issue of entitlement to service connection for sleep apnea for further development. While on remand, service connection for sleep apnea was granted in an October 2020 rating decision. As this constitutes a full grant of the benefits sought, that issue is also no longer on appeal before the Board. Id. Earlier Effective Dates Unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication or a claim for increase shall be fixed in accordance with the facts found, but not earlier than the date the claim was received. 38 U.S.C. § 5110(a) (2012). Effective March 24, 2015, VA amended its regulations to require that in order to be considered a valid claim, a claim for benefits must be submitted on a standardized form. 79 Fed. Reg. 57,660 (Sept. 25, 2014) (eff. Mar. 24, 2015). However, this amendment only applies to claims or appeals filed on or after March 24, 2015. Id. at 57,686. Under the law prior to the amendment, a claim was defined as a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1(p) (2014) (amended 2015). An informal claim was any communication or action indicating an intent to apply for one or more benefits that identifies the benefit sought. 38 C.F.R. § 3.155(a) (2014) (repealed 2015). Under the law at the time, VA had an obligation to look to all communications from a claimant that may be interpreted as applications or claimsformal and informalfor benefits and was required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). In addition, in cases involving previously denied claims reports of examination or hospitalization from VA or a uniformed service or private medical records may constitute informal claims to reopen. 38 C.F.R. § 3.157(b). Upon receipt of an informal claim for benefits, if a formal claim for benefits had not been filed, VA was required to provide the Veteran with a formal claim form for the Veteran to complete and return. 38 C.F.R. § 3.155(a) (2014). If a formal claim for benefits was then filed within one year of the date the formal claim form was sent to the Veteran, the formal claim was considered to have been filed as of the date of receipt of the informal claim. Id. Following the March 2015 amendment, a claim for benefits must be filed on the standardized claim form prescribed by the Secretary. 38 C.F.R. §§ 3.150, 3.151 (2017). A veteran may also indicate their intent to file a claim for compensation by submitting an intent to file a claim to VA. 38 C.F.R. § 3.155(b) (2017). Upon receipt of the intent to file a claim, VA must provide the claimant with the appropriate claims form. Id. If a complete application for benefits on the form prescribed by the Secretary is received by VA within one year of receipt of the intent to file, VA will consider the formal claim to have been filed as of the date the intent to file a claim was received. Id. An intent to file a claim must be submitted using one of three approved methods and must identify the general benefit and the claimant. Id. 1. Earlier effective date for service connection for an adjustment disorder. In this case, the Veteran filed an original claim for service connection for "stress" as secondary to psoriasis on March 29, 2010. In a rating decision issued in October 2010, the RO denied entitlement to service connection for "stress," to include as secondary to psoriasis, stating that "stress" in and of itself is not a disability for VA purposes nor was the Veteran actually service connected for psoriasis. The Veteran was notified of the decision, but did not file a notice of disagreement. 38 C.F.R. §§ 20.200, 20.201, 20.302. No evidence was physically or constructively associated with the file during the one-year appellate period following the decision. 38 C.F.R. § 3.156(b); see Lang v. Wilkie, 971 F.3d 1348, 135355 (Fed. Cir. 2020). As such, the March 2010 claim for service connection for "stress" was finally denied in October 2010, and did not remain pending. The Board notes that at the time of the October 2010 rating decision, the Veteran's service treatment records were noted to be unavailable. These records were then subsequently associated with the file in January 2015. However, while new the records are not relevant. "Relevant" means service records that speak to a matter in issue or in dispute. Kisor v. Wilkie, 969 F.3d 1333, 134143 (Fed. Cir. 2020). In other words, to be relevant the new service department records must pertain to the basis of the prior final denial. Id. Here, none of the service treatment records reflect a diagnosis of a psychiatric disability of any kind in service or treatment for any symptoms indicative a psychiatric disability. As the records contain no information showing that a psychiatric disability was incurred or aggravated by service, they are not relevant and therefore de novo review of the previously denied claim is not warranted. 38 C.F.R. § 3.156(c); Kisor, 969 F.3d at 134143. As the March 29, 2010 claim for service connection for stress was finally denied, it cannot be used as the date of claim in this case. Following the October 2010 denial, on July 2, 2018 the Veteran submitted an intent to file form. On July 3, 2018, VA received a formal claim form on which the Veteran stated that he was claiming service connection for PTSD due to personal trauma, service connection for an adjustment disorder with depressed mood secondary to psoriasis, and reopening of service connection for "stress." In a rating decision issued in January 2019, the RO granted service connection for an adjustment disorder as secondary to psoriasis. As the formal claim for service connection for an adjustment disorder was received within one year of the Veteran's intent to file form, the RO assigned an effective date of July 2, 2018, the date of receipt of the intent to file. 38 C.F.R. § 3.155(b) (2017). Between the October 2010 rating decision and the July 2, 2018 intent to file, there are no claims, whether formal or informal, which expressed an intent to file for benefits for an adjustment disorder specifically or a psychiatric disability generally. It is uncontroverted that none of the formal claims filed by the Veteran during this period identified an adjustment disorder specifically or a psychiatric disability generally as a claimed disability. 38 C.F.R. §§ 3.150, 3.151 (2017). Further, there is no evidence in the file that the Veteran filed any other intent to file forms within one year prior to the July 3, 2018 formal claim identifying an adjustment disorder as a claimed disability. 38 C.F.R. § 3.155(b) (2017). Instead, the argument currently advanced by the Veteran's attorney is that a statement submitted by the Veteran received on January 30, 2015 constituted an informal claim for service connection for a psychiatric disability. As this submission was received prior to the March 2015 amendment and the repeal of the regulation allowing for informal claims, the Board must determine whether the statement meets the requirements to be considered an informal claim for an adjustment disorder. As noted above, an informal claim was any communication or action indicating an intent to apply for one or more benefits that identifies the benefit sought. 38 C.F.R. § 3.155(a) (2014) (repealed 2015). In order to be legally sufficient, a claim must identify the sickness, disease or injury for which benefits are being sought at least a high level of generality. Sellers v. Wilkie, 965 F.3d 1328, 1338 (Fed. Cir. 2020); see Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). However, in determining whether a filing sufficiently identifies the benefits sought, the identification need not necessarily be in the claim-stating documents, but instead can be found through evidence identified in the claim documents. Shea v. Wilkie, 926 F.3d 1362, 136970 (Fed. Cir. 2019). Turning to the January 30, 2015 statement, the statement was filed approximately one month after the Veteran filed a December 2014 claim to reopen service connection for psoriasis, and approximately two weeks after filing a claim to reopen a claim for service connection for joint pain. In the statement itself, the Veteran begins by asserting that he has a severe case of plaque psoriasis which had its onset in 1987 or 1988, during his period of active service. The statement then proceeds to detail the symptoms associated with the psoriasis, including their frequency and severity, and the medications he uses for treatment. The Veteran further stated that the plaque psoriasis causes him embarrassment in the second and fourth paragraph and that the psoriasis affects him "emotionally," causes him to be moody, and affects his "mental capacity" in the fourth paragraph. The Veteran then concluded by requesting "VA assistance and compensation for this dreaded condition." The Veteran's attorney in their October 2021 appellate brief first asserts that the Veteran expressed an intent to file for benefits in the December 2014 and January 2015 claims, and then sufficiently identified a disability in the January 2015 statement, and cites to Brokowski for support. However, the portion of Brokowski cited in the appellate brief discusses a different, and hypothetical, situation from that present in the current case. In Brokowski, it was noted that hypothetically speaking a generic statement expressing an intent to file for "all disabilities of record" when submitted with medical records documenting specific disabilities would potentially satisfy the requirements for a valid informal claim. Brokowski v. Shinseki, 23 Vet. App. 79, 8889 (2009). In this case, the December 2014 and January 2015 formal claims did not express such general intent to file for benefits. Instead, they expressed an intent to file for benefits for specific disabilities identified on the forms. Further, as discussed in detail below the January 2015 statement does not sufficiently identify a psychiatric disability for which benefits are being claimed. Therefore, the December 2014 and January 2015 formal claims for service connection for psoriasis and joint pain, respectively, are not also claims for service connection for an adjustment disorder. Second, the attorney asserts that the January 2015 statement itself expresses both an intent to file for a benefit and sufficiently identified the claimed disability. In support of this assertion, the attorney highlights the Veteran's statements that his psoriasis resulted in him feeling "embarrassed" or "moody" and that his psoriasis affected his "mental capacity." However, these assertions do not, even at a high level of generality, identify a psychiatric disability. These statements in no way indicate that the Veteran had a psychiatric disability or was receiving treatment for one, or that there was a separate psychiatric disability as a result of his psoriasis. Instead, the statement is more naturally read as the Veteran detailing the physical and functional impairment resulting from his psoriasis, which was being offered in support of the claim for service connection for psoriasis the Veteran had filed the previous month. Indeed, the Veteran demonstrated in the January 2015 statement that he was fully capable of identifying any and all claimed disabilities, as he specifically stated at the outset of the January 2015 statement that he was currently diagnosed with plaque psoriasis that had been present since his period of service. Further, the Veteran had previously filed several formal and informal claims for different disabilities, including a prior claim specifically expressing an intent to file for service connection for a psychiatric disability, claimed as "stress," as secondary to psoriasis. Thus, both the January 2015 statement itself and the other claims of record clearly reflect that had the Veteran intended to express an intent to file for service connection for a psychiatric disability in the January 2015 he knew how to adequately express that intent. The attorney further points to the Veteran's request in the January 2015 statement for "assistance and compensation for this dreaded condition" as expressing intent to file for benefits for an identified psychiatric disability. However, a plain reading of this statement leads to the conclusion that the Veteran was requesting compensation for only one disability, and that was psoriasis. The only disability clearly identified as having been diagnosed in the January 2015 statement was psoriasis, and the entire statement was phrased as a recitation of the symptoms associated with his psoriasis and functional and societal impairments the Veteran faced as a result of the disability. Indeed, use of the phrase "this dreaded condition," phrased in the singular, only reinforces that the statement was intended to support a claim for service connection for only one disability, psoriasis. Finally, none of the evidence submitted along with, or in close temporal proximity to, either of the formal claims or the January 2015 statement reflects that the Veteran was diagnosed with a psychiatric disability of any kind. Shea, 926 F.3d at 136970; Brokowski, 23 Vet. App. at 8889. Private treatment records submitted at roughly the same time as the January 2015 statement show treatment for psoriasis but no complaints of, treatment for, or a diagnosis of psychiatric symptoms or disabilities associated with the psoriasis. As such, even when also considering the other documentation submitted with or in close proximity to the January 2015 statement there is nothing of record either identifying a psychiatric disability or expressing an intent to file for service connection for a psychiatric disability. Shea, 926 F.3d at 136970; Brokowski, 23 Vet. App. at 8889. In light of the foregoing, the Board finds that the January 2015 statement did not express an intent to apply for benefits for a psychiatric disability that was identified at even a high-level of generality. As such, the January 2015 statement does not constitute a valid informal claim to reopen the claim for service connection for a psychiatric disability. 38 C.F.R. § 3.155(a) (2014) (repealed 2015). A review of the record does not reflect any other statements from the Veteran in which he expressed an intent to file for benefits for a psychiatric disability or requested to reopen a claim for service connection for a psychiatric disability. No VA reports of examination or hospitalization concerning a psychiatric disability were associated with the file, nor were any private treatment records submitted indicating it was reasonably probable that the Veteran was entitled to benefits for a psychiatric disability. 38 C.F.R. § 3.157(b). Finally, as noted above while additional service records were associated with the file since the prior October 2010 denial of service connection, these records are not relevant. Further, as service connection for an adjustment disorder was granted as secondary to psoriasis, the eventual grant of service connection for an adjustment disorder was not based on the treatment records in any way. Thus, an earlier effective date based on the receipt of such records is not possible. 38 C.F.R. § 3.156(c). Therefore, July 2, 2018 is the appropriate date of claim in this case. As an effective date for an award of service connection based on a reopened claim may not be earlier than the date of receipt of the claim to reopen, entitlement to an earlier effective date is not warranted. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(r). Based on the above, an effective date prior to July 2, 2018, for the award of service connection for an adjustment disorder is not warranted. The September 2010 rating decision denying the claim for service connection for "stress" became final, and no new, relevant service department records were associated with the file following its issuance. Further, between the October 2010 rating decision and the July 2, 2018, intent to file form, no other formal or informal claims expressing any intent to apply for service connection for a psychiatric disability, even at a high level of generality, were received. As such, an effective date prior to July 2, 2018, for the award of service connection for an adjustment disorder is denied. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(r). New and Material Evidence Where a claim has been finally adjudicated, a claimant must present new and material evidence to reopen the previously denied claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). New evidence is evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). Material evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be either cumulative or redundant of the evidence of record at the time of the last prior final denial and must raise a reasonable possibility of substantiating the claim. Id. New and material evidence received prior to the expiration of the appeal period following a decision, will be considered as having been filled in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). The definitions of the terms "new" and "material" for the purposes of this provision are the same as those discussed above. Voracek v. Nicholson, 421 F.3d 1299, 1304 (Fed. Cir. 2005). If evidence received during the appellate period following a decision is new and material, the claim will remain pending until VA issues another decision re-adjudicating the claim and addressing the new and material evidence. Bond v. Shinseki, 659 F.3d 1362, 136768 (Fed. Cir. 2011). New and material evidence is not required to reopen a claim when, at any time after VA issues a decision on a claim, VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim. 38 C.F.R. § 3.156(c). "Relevant" means service records that speak to a matter in issue or in dispute. Kisor v. Wilkie, 969 F.3d 1333, 134143 (Fed. Cir. 2020). In other words, to be relevant the new service department records must pertain to the basis of the prior final denial. Id. For the purposes of reopening a claim, newly submitted evidence is generally presumed to be credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). New and material evidence is not required as to each previously unproven element of a claim in order to reopen. Shade v. Shinseki, 24 Vet. App. 110, 120 (2010). There is a low threshold for determining whether evidence raises a reasonable possibility of substantiating a claim. Id. at 11718. 2. Reopening of the claim for service connection for joint pain. In a rating decision issued in October 2010, the RO denied entitlement to service connection for joint pain, to include as secondary to psoriasis, stating that the disability was not incurred in or aggravated by service and was not caused or aggravated by a service-connected disability. The Veteran was notified of the decision, but did not initiate an appeal. 38 C.F.R. §§ 20.200, 20.201, 20.302. No evidence was physically or constructively associated with the file during the one-year appellate period following the decision. 38 C.F.R. § 3.156(b); see Lang, 971 F.3d at 135354. The Board notes that at the time of the October 2010 rating decision, the Veteran's service treatment records were noted to be unavailable. These records were then subsequently associated with the file in January 2015. However, while the records are new, they are not relevant. "Relevant" means service records that speak to a matter in issue or in dispute. Kisor, 969 F.3d at 134143. In other words, to be relevant the new service department records must pertain to the basis of the prior final denial. Id. Here, none of the service treatment records reflect treatment for generalized joint pain or a diagnosis of any arthritic disability in service. As the records contain no information showing that the Veteran's generalized joint pain, or an arthritic disability specifically, was incurred or aggravated by service, they are not relevant and therefore de novo review of the previously denied claim is not warranted. 38 C.F.R. § 3.156(c); Kisor, 969 F.3d at 134143. The evidence of record in October 2010 consisted of VA and private treatment records and lay statements from the Veteran and his spouse. Evidence received since the rating decision includes private opinions stating that the Veteran is diagnosed with psoriatic arthritis that is due to his service-connected psoriasis. There is no evidence the opinions are not competent, and they are presumed credible for the purposes of reopening. Justus, 3 Vet. App. at 513. The evidence provided by the Veteran is new as it was not previously submitted to agency decision makers and is material as it addresses the previously unestablished fact of a nexus between the reported joint pain and a service-connected disability. It is not redundant and raises a reasonable possibility of substantiating the claim. Therefore, reopening of the claim for service connection for joint pain is warranted. REASONS FOR REMAND 1. Entitlement to an increased rating for psoriasis. During the course of the current appeal, the Veteran submitted medical opinions from private providers in October 2015 and November 2018. Both physicians noted in the opinions that they had been treating the Veteran for his disabilities, including his psoriasis, on a consistent basis for a long period of time. However, a review of the record reflects only sporadic private treatment records have been associated with the file. As both private opinions indicate there are outstanding private treatment records that may be relevant to the Veteran's claim for an increased rating for his psoriasis, a remand is warranted so that attempts may be made to obtain the records. 38 C.F.R. § 3.159(c)(1). 2. Entitlement to service connection for headaches, a cervical spine disability, and a low back disability. VA obtained medical opinions concerning the etiology of the Veteran's cervical spine and low back disabilities in July 2015, and an opinion concerning the etiology of the Veteran's headaches in November 2018. In pertinent part, each opinion stated that the disabilities were less likely than not proximately due to or caused by a service connected disability. However, none of the opinions specifically address the question of aggravation, rendering them inadequate. El-Amin v. Shinseki, 26 Vet. App. 136, 14041 (2013); see also Allen v. Brown, 7 Vet. App. 439 (1995). As such, these issues must be remanded so that new opinions may be obtained. 3. Entitlement to service connection for joint pain. First, as discussed with respect to the claim for an increased rating for psoriasis above, private medical opinions from October 2015 and November 2018 reflect that the Veteran receives private treatment for possible psoriatic arthritis. However, only sporadic private treatment records have been associated with the file. As these records may contain information clarifying the nature of the Veteran's claimed joint pain, the issue must be remanded so that attempts may be made to obtain the records. 38 C.F.R. § 3.159(c)(1). Second, the Veteran was provided with a non-degenerative arthritis examination in November 2018. The examiner provided a diagnosis of osteoarthritis, and stated that the x-ray findings obtained at the time of the examination were not indicative of psoriatic arthritis. However, in opining that the Veteran did not have psoriatic arthritis the examiner did not address the October 2015 private opinion stating that the Veteran had psoriatic arthritis affecting his fingers, toes, knees, elbows, and shoulders. As such, a remand is necessary so that another examination can be provided to clarify the nature of the Veteran's disability. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. Contact the Veteran and request that he submit or authorize for release all private treatment records relevant to his claimed disabilities, including psoriasis. For all records authorized for release, if the search for these records is negative the Veteran must be informed of this in writing in accordance with 38 C.F.R. § 3.159(e). 3. Obtain a medical opinion concerning the etiology of the claimed headaches. The examiner should answer the following: a) Is it at least as likely as not (a fifty percent probability or greater) that the claimed headaches are causally related to the Veteran's active service? In answering (a), attention is invited to the following: (1) a June 1990 service treatment record noting a complaint of headaches (labelled "STR - Medical - Photocopy" pg. 12 uploaded 1/12/15); and, (2) a June 1995 VA examination diagnosing tension headaches (labelled "VA Examination" uploaded 6/17/95). b) Is it at least as likely as not (a fifty percent probability or greater) that the headaches were caused by the service-connected psoriasis? c) If not, is it at least as likely as not (a fifty percent probability or greater) that the headaches were aggravated (worsened) by the psoriasis? In answering (b) and (c), attention is invited to a November 2018 private opinion stating that the Veteran's headaches are due to his psoriasis (labelled "Medical Treatment Record - Non-Government Facility" uploaded 12/3/18). A detailed rationale for the opinion must be provided. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 4. Obtain a medical opinion concerning the etiology of the claimed cervical spine disability. The examiner should answer the following: a) Is it at least as likely as not (a fifty percent probability or greater) that the claimed cervical spine disability is causally related to the Veteran's active service? b) Is it at least as likely as not (a fifty percent probability or greater) that the cervical spine disability was caused by the service-connected psoriasis? c) If not, is it at least as likely as not (a fifty percent probability or greater) that the cervical spine disability was aggravated (worsened) by the psoriasis? In answering (b) and (c), attention is invited to a November 2018 private opinion stating that the Veteran's cervical spine disability is due to his psoriasis (labelled "Medical Treatment Record - Non-Government Facility" uploaded 12/3/18). A detailed rationale for the opinion must be provided. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 5. Obtain a medical opinion concerning the etiology of the claimed low back disability. The examiner should answer the following: a) Is it at least as likely as not (a fifty percent probability or greater) that the claimed low back disability is causally related to the Veteran's active service? b) Is it at least as likely as not (a fifty percent probability or greater) that the low back disability was caused by the service-connected psoriasis? c) If not, is it at least as likely as not (a fifty percent probability or greater) that the low back disability was aggravated (worsened) by the psoriasis? In answering (b) and (c), attention is invited to a November 2018 private opinion stating that the Veteran's low back disability is due to his psoriasis (labelled "Medical Treatment Record - Non-Government Facility" uploaded 12/3/18). A detailed rationale for the opinion must be provided. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 6. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's joint pain. The examiner should answer the following: a) Identify all current arthritic conditions. Attention is invited to the following: (1) a November 2018 VA examination diagnosing osteoarthritis affecting the feet and toes and arthritic pain in the knees and ruling out psoriatic arthritis (labelled "C&P Exam" uploaded 11/30/18); (2) an October 2015 private medical opinions diagnosing the Veteran with psoriatic arthritis of the bilateral fingers, toes, knees, elbows and shoulders (labelled "Correspondence" uploaded 11/4/15); and, (3) a November 2018 private opinion noting a diagnosis of psoriatic arthritis (labelled "Medical Treatment Record - Non-Government Facility" uploaded 12/3/18). b) For all disabilities so identified, is it at least as likely as not (a fifty percent probability or greater) that the arthritic disability was caused by the service-connected psoriasis? c) If not, is it at least as likely as not (a fifty percent probability or greater) that the arthritic disability was aggravated (worsened) by the psoriasis? A detailed rationale for the opinion must be provided. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Wendell, 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.