Citation Nr: 21077343 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 18-48 090 DATE: December 29, 2021 REMANDED Entitlement to an evaluation in excess of 10 percent disabling for degenerative joint disease (DJD), lumbosacral spine is remanded. Entitlement to an evaluation in excess of 10 percent disabling for cervical spine degenerative disc disease (DDD) is remanded. Entitlement to a compensable evaluation for hypertension is remanded. Entitlement to a compensable evaluation for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for pseudofolliculitis barbae is remanded. Entitlement to service connection for vertigo disorder is remanded. Entitlement to service connection for elective vasectomy is denied. REASONS FOR REMAND The Veteran served on active duty from April 1982 to September 2002. Entitlement to an evaluation in excess of 10 percent disabling for DJD, lumbosacral spine is remanded. Entitlement to an evaluation in excess of 10 percent disabling for cervical spine DDD is remanded. Entitlement to a compensable evaluation for hypertension is remanded. Entitlement to a compensable evaluation for GERD is remanded. In an April 2021 Board hearing, the Veteran asserted that the disabilities noted above have increased in severity since the Veteran was last examined by VA in February 2015. The Veteran should be provided an opportunity to report for applicable VA examinations to ascertain the current severity and manifestations of each disability. Entitlement to service connection for pseudofolliculitis barbae is remanded. The Veteran's service treatment records indicate that he was treated for pseudofolliculitis barbae during active service. Current treatment records indicate that the Veteran has been treated for an additional skin condition. Finally, in his April 2021 Board hearing, the Veteran complained of current symptoms of a skin condition and noted previous private treatment by a dermatologist. Accordingly, the Board notes that it cannot make a fully-informed decision on the issue of pseudofolliculitis barbae because no VA examiner has opined whether his current skin manifestations are the result of his active service and complaints therein. Entitlement to service connection for vertigo disorder is remanded. The Veteran's service treatment records indicate that he was treated for motion sickness during active service. Further, in his April 2021 Board hearing, the Veteran complained of current symptoms possibly related to vertigo. Accordingly, the Board notes that it cannot make a fully informed decision on the issue of vertigo because no VA examiner has opined whether his current symptoms are the result of his active service and complaints therein. Entitlement to service connection for elective vasectomy is remanded. The Veteran is also seeking service connection for residuals of a vasectomy. The Veteran did undergo an elective vasectomy procedure in service. The Board notes that without any residuals, service connection cannot be awarded for an elective sterilization procedure. However, at the Board hearing, the Veteran reported "trauma" and pain due to the vasectomy. As such, the Board finds that an examination is necessary to determine whether the Veteran suffers from any residuals of the vasectomy. The matters are REMANDED for the following action: 1. Obtain and associate with the record any outstanding VA treatment records for the Veteran. 2. Ask the Veteran to complete a VA Form 21-4142 for the Dermatologist noted during his April 2021 Board Hearing. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected lumbar disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. (a.) The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (b.) the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training) 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected cervical spine disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. (a.) The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (b.) the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training) 5. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected hypertension. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected GERD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. 7. Schedule the Veteran for a VA examination for his pseudofolliculitis barbae. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is any diagnosed skin disorder at least as likely as not related to service? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 8. Schedule the Veteran for a VA examination for his vertigo. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is any diagnosed vertigo at least as likely as not related to service? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 9. Afford the Veteran an appropriate VA examination to address the etiology of the Veteran's claimed residuals of a vasectomy. All pertinent evidence of record must be made available to and reviewed by the examiners. Any indicated studies should be performed. The examiner should clearly delineate whether the Veteran suffers from any residual symptoms from the in-service vasectomy surgery, to include his claims of "trauma" and pain. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. A. Elliott II, 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.