Citation Nr: 21005467 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 12-03 620 DATE: February 1, 2021 ORDER Entitlement to service connection to left knee disability, to include as secondary to service-connected squamous cell carcinoma residuals, is denied. Entitlement to service connection to right knee disability, to include as secondary to service-connected squamous cell carcinoma residuals is denied. Entitlement to an increased rating in excess of 10 percent for tinea versicolor is denied. Entitlement to a compensable rating for residuals of squamous cell carcinoma of the rectum, also referred to as rectal cancer, is denied. Entitlement to an increased rating in excess of 60 percent for fecal incontinence is denied. Entitlement to a separate rating of 50 percent, but no higher, for rectal stricture is granted. REMAND Entitlement to service connection for left hip disability, to include as secondary to service-connected squamous cell carcinoma residuals is remanded. FINDINGS OF FACT 1. The probative evidence of record does not show that the Veteran’s bilateral knee conditions are related to her active duty service. 2. The Veteran’s tinea versicolor has not manifested lesions involving 20 to 40 percent of the entire body or of exposed areas; systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. 3. The evidence of record does not show the Veteran’s residuals of squamous cell carcinoma of the rectum have manifested to exclusive skin growths, hernias of any kind, malignant neoplasms or other digestive diseases. 4. The Veteran’s fecal incontinence has not manifested to complete loss of sphincter control. 5. The probative evidence of record shows the Veteran suffers from rectal stricture related to her squamous cell carcinoma residuals. CONCLUSIONS OF LAW 1. The criteria for service connection to left knee disability, to include as secondary to service-connected squamous cell carcinoma residuals, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 2. The criteria for service connection to right knee disability, to include as secondary to service-connected squamous cell carcinoma residuals, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 3. The criteria for an increased rating in excess of 10 percent for tinea versicolor have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7813. 4. The criteria for a compensable rating for residuals of squamous cell carcinoma of the rectum have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7344. 5. The criteria for an increased rating in excess of 60 percent for fecal incontinence have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7332. 6. The criteria for a separate rating of 50 percent, but no higher, for rectal stricture have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7333. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Marine Corps from April 1969 to April 1973. In September 2016, a Board hearing was held by a Veterans Law Judge (VLJ) who is no longer with the Board. In May 2020, the Board notified the Veteran of her right to a second hearing with a new VLJ. The Veteran did not respond to the notification, and thus, the Board has moved on with the appeal. The claims were brought before the Board in February 2017 and August 2020 and were remanded for further development. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).  In order to establish service connection, the record must show competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability.  Holton v. Shinseki, 557 F.3d, 1362, 1366 (Fed. Cir. 2009).  Certain chronic diseases, including arthritis, will be presumed related to service if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). When considering such a claim for service connection, the Board must consider on a case-by-case basis, the competence and sufficiency of lay evidence offered to support a finding of service connection.  See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 Fed. Cir. 2007)).  The mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient.  Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Entitlement to Service Connection: Bilateral Knee Conditions The Veteran contends that she currently suffers from left and right knee conditions that are related to her active duty service, to include as due to or aggravated by her service-connected squamous cell carcinoma residuals. As an initial matter, the Board acknowledges that the Veteran has diagnoses of degenerative arthritis of the left and right knees. Thus, the issue turns upon whether there is evidence of an in-service event or injury and a nexus between the claimed in-service event or injury and the present disability. See Sheldon v. Prinicipi 381 F.3d 1163, 1167 (Fed. Cir. 2004).  The Board finds there is not.  In January 2018, the Veteran was provided a VA examination. The examiner opined that the Veteran’s condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner rationalized that the Veteran’s service treatment records are silent for a bilateral knee condition. The Veteran’s separation examination also did not list a knee condition. The examiner noted that the earliest evidence of a knee condition was in 2010, which is over 30 years after the Veteran’s service. The examiner also opined that the Veteran’s conditions were not due to or aggravated by her service-connected rectal cancer. The examiner rationalized that the Veteran has bilateral knee osteoarthritis, which is due to normal wear and tear of a joint. The examiner stated there was no evidence in the Veteran’s records showing her knees were targets during radiation treatment for her cancer. The examiner further stated that radiation treatment and chemotherapy do not cause arthritis of the distal joint. The examiner also noted there was no evidence of aggravation beyond natural progression. The Board notes that VA treatment records show complaints for bilateral knee pain. However, none of these records relate the Veteran’s conditions to her active duty service, to include her service-connected squamous cell carcinoma cancer. Further, the evidence of record does not show complaints for bilateral knee pain until 2010, and by the Veteran’s own reports, she did not begin to have bilateral knee pain until the early 2000s. Therefore, the Board finds January 2018 VA opinion to be of significant probative value in determining that the Veteran’s bilateral knee condition is not related to her period of service.  The Board notes that the probative value of medical opinion evidence is based on the medical experts’ personal examination of the patient, their knowledge, and skill in analyzing the data, and their medical conclusion.  As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator.  Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993).  Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits.  See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998).  Here, the reviewing physician’s opinion was based on review of the Veteran’s lay contentions, her reported medical history, medical literature, and review of the medical evidence of record.  Further, a complete and thorough rationale was provided for the opinions rendered.  The Board acknowledges the Veteran’s assertions her bilateral knee conditions are due to her active duty service or her service-connected squamous cell carcinoma.  The Board recognizes that lay persons are competent to provide medical opinions on some medical issues.  See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011).  However, although the Veteran is competent to report her symptoms, any opinion regarding whether any knee disability is related to her military service or to a service-connected disability requires medical expertise that the Veteran has not demonstrated since knee disabilities can have many causes.  See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (2007).  As the Veteran has a diagnosis of arthritis, the Board has also considered presumptive service connection or service connection based on a continuity of symptomatology.  However, there is no evidence that the Veteran had a left or right knee disability that manifested within one year after discharge from service.  To the extent that the Veteran asserts that she experienced a bilateral knee disability continuously since discharge from service, the Board again notes that the Veteran has provided no evidence showing treatment for a left or right knee condition until 2010, over 35 years after her active duty service, and reported she began feeling knee pain in the early 2000s. Thus, any lay statements asserting continuity of symptomatology since discharge from service are not credible. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the claims and the benefit of the doubt doctrine is not for application.  See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran’s service-connected disability adversely affects his/her ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned 38 C.F.R. § 4.7. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Additionally, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the veteran’s claim is to be considered. See Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. However, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an Increased Rating: Tinea Versicolor The Veteran’s service-connected tinea versicolor is currently rated as 10 percent disabling under Diagnostic Code (DC) 7813 for Tinea Versicolor under the General Rating Formula for the Skin. Relevant to the applicable period on appeal, VA recently amended the rating criteria for skin conditions, effective August 13, 2018. See 83 Fed. Reg. 32,597 (July 13, 2018); 83 Fed. Reg. 38,663 (Aug. 7, 2018). In cases where rating criteria are amended during the course of the appeal, the Board must consider both the former and current schedular criteria. Should an increased rating be warranted under new, revised criteria, the award may not be made effective before the effective date of change. See Kuzma v. Principi, 341 F.3d 1327, 1328 (Fed. Cir. 2003). Currently, DC 7813 is rated under the General Rating Formula for the Skin. The General Rating Formula for the Skin provides for a noncompensable rating where the condition requires no more than topical therapy over the past 12-month period and at least one of the following: Characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. 38 C.F.R. § 4.117, DC 7813. A 10 percent rating is warranted for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, or exposed areas affected; or, intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is warranted for at least one of the following: characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. Id. A 60 percent rating is warranted for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. Id. Comparatively, under the prior version, Diagnostic Code 7813 directed VA adjudicators to evaluate the disability as either disfigurement of the head, face, or neck (Diagnostic Code 7800); scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805); or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. The Board notes the Veteran’s tinea versicolor was more closely represented by DC 7806 for dermatitis, and thus, was rated as such. Under the prior version of Diagnostic Code 7806, a noncompensable rating was warranted when less than 5 percent of the entire body or less than 5 percent of exposed areas was affected, and no more than topical therapy was required during the past 12-month period. A 10 percent rating was warranted when at least one of the following was present: 5 to 20 percent of the entire body or 5 to 20 percent of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating was warranted where at least one of the following was present: 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating was assigned when either more than 40 percent of the entire body or exposed areas was affected, or; the skin condition required constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. In October 2009, the Veteran was provided a VA examination. The Veteran reported the time course as constant. She had intermittent pruritus, with no pain, no weight loss, and no systemic symptoms. There was no history of urticaria, vasculitis, or erythema multiforme. She had been treated with antifungal creams and sulfur soaps, which did not work. She had not been treated with corticosteroids, immunosuppressives, or light therapy. The tinea versicolor was mainly on her abdomen and can spread if she is hot and sweaty. She reported it was worse in the sun. The examination of the skin revealed areas of erythremia with some hyperpigmented patches on her lower chest and upper abdomen. The percentage of the chest and abdomen involved were 4 percent each. The percentage of exposed area was 0 percent, and the percent of the total body affected was 8 percent. In October 2011, the Veteran received another VA examination. The Veteran reported eruptions that are maculopapular, erythematous, itchy, affecting the neck, upper chest, and the front of both legs. She reported not being currently on any medication. Her lesions were recurrent and come back at least two times a year. Her last episode was 6 months prior. On examination, there was no rash present. The examiner noted that based on the Veteran’s description the condition affected approximately 6 percent of the total skin surface and 0 percent of the exposed skin surface. In May 2012, the Veteran was provided a VA examination. The Veteran reported not being on any medication for it. She reported it affecting her arms and spreading to her back and chest in the summer when she is in the sun or in the pool. She reported intermittent pruritus but no pain. The condition did not involve scarring or disfigurement of the head, face, or neck. She had no benign or malignant skin neoplasms. The Veteran did not have any systemic manifestations due to any skin diseases. She did not have any oral or topical medications in the past 12 months. She also did not have any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous. The Veteran had no debilitating or non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in the past 12 months. The Veteran’s condition was noted as affecting 5 percent or less of her total body area and did not affect any exposed area of her body. The Veteran was provided another VA examination in January 2018. The Veteran reported intermittent flare-ups that affects her bilateral arms and back. She reported discolored circular lesions when present. She reported it only occurs during the warmer months. Her condition did not affect the head, face, or neck. There were no benign or malignant skin neoplasms. The Veteran did not have any systemic manifestation due to any skin diseases. The Veteran was not being treated with oral or topical medications in the past 12 months. The Veteran did not have any debilitating episodes or non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in the past 12 months. The Veteran’s skin condition was noted as affecting 5 percent or less of her total body area and 5 percent or less of her exposed area. Her condition consisted of sparse, circular hypopigmented lesions on her bilateral forearms. After review of the evidence of record, the Board finds that a rating in excess of 10 percent is not warranted. The Veteran’s condition has mainly manifested to at least 5 percent, but less than 20 percent, of the entire body or at least 5 percent, but less than 20 percent, of exposed areas are affected; or, intermittent systemic therapy such as corticosteroids, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks during a 12-month period. The Board notes that the evidence has consistently shown that the Veteran’s tinea versicolor has affected less than 10 percent of her total body, and has not required any medications such as corticosteroids, photochemotherapy, PUVA, or other immunosuppressive drugs for more than 6 weeks. In fact, she often reported using no medication, topical or oral, for her condition during examinations. Therefore, the Board finds that a rating in excess of 10 percent is not warranted. The Board acknowledges the Veteran’s assertions that her tinea versicolor warrants a higher rating. The Board recognizes that lay persons are competent to provide medical opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, although the Veteran is competent to report her symptoms, any opinion regarding the percentage of the body affected by a disability requires medical expertise that the Veteran has not demonstrated. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (2007). In light of the foregoing, the Board concludes that a rating in excess of 10 percent is not warranted. The benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 1. Entitlement to Increased Rating: Squamous Cell Carcinoma Residuals The Veteran’s squamous cells carcinoma residuals of the rectum are currently provided a non-compensable rating under Diagnostic Code 7344 for Benign Neoplasms Skin Growths. Diagnostic Code 7344 provides that the disability should be evaluated under an appropriate diagnostic code, depending on the predominant disability or the specific residuals after treatment. Id. This rating code does not contain provisions for a zero percent, or noncompensable evaluation. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. In March 2010, the Veteran was provided a VA examination. The Veteran reported anal itching, diarrhea, and pain with anal discharge. She had no fissures, no hemorrhoids, no evidence of bleeding of rectal relapse. The Veteran reported no hernia and no fistulas were noted. In September 2010, the Veteran was provided another VA examination. On examination, the Veteran had no fissures, external hemorrhoids, and no rectal prolapse. There was irritation in the peri-anal region noted. The Veteran was again seen for an examination in January 2018. No fissures, hemorrhoids, or evidence of bleeding of rectal relapse were noted. The Veteran reported sores on her rectum. On examination, it was noted the skin was raw surrounding the anus with the appearance of frequent irritation. There were no open lesions or redness noted. The Board notes that the evidence of record does not show the Veteran has any skin growths, benign or malignant, hernias, hemorrhoids, fistulas, or other visible growths related to her squamous cell carcinoma residuals. Regarding her urinary and fecal incontinence, the Veteran has already been provided separate ratings for such conditions under their pertinent diagnostic codes. The Board lastly notes that the Board will be granting a separate rating for her rectal stricture below. Diagnostic Code 7344 does not contain specific ratings, indicating that the predominant disability should be rated. Here, the Veteran’s complaints of anal pain and soreness are not disabilities under the criteria. Where the rating schedule does not provide a zero percent (noncompensable) evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. There is no argument or indication that another diagnostic code would be more appropriate. Therefore, the Board finds that a compensable rating for squamous cell carcinoma of the rectum residuals is not warranted. The benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 2. Entitlement to an Increased Rating: Fecal Incontinence The Veteran’s service-connected fecal incontinence is currently rated as 60 percent disabling under Diagnostic Code (DC) 7332 for Impairment of Sphincter Control. Under Diagnostic Code 7332, a 60 percent rating is provided for impairment of sphincter control that causes extensive leakage and fairly frequent involuntary bowel movements. Complete loss of sphincter control is assigned a total 100 percent rating. 38 C.F.R. § 4.114, DC 7332. In March 2010, the Veteran was provided a VA examination. The Veteran reported occasional fecal incontinence. She reported only wearing diapers or Depends if she is going out in public and unsure where a bathroom is. Her fecal incontinence was not extensive. She reported painful bowel movements, pain when she wipes her rectum, and anal irritation. In September 2010, the Veteran was seen again for an examination. She reported significant issues of fecal incontinence, chronic intermittent diarrhea, rectal bleeding and peri-anal pruritis. She reported wearing Depends most of the time and carrying wipes because she has bowel movements of loose consistency at times, up to 7 times in a 2-hour period, and has chronic leakage. She also reported that she has 10 to 15 bowel movements a day and significant anal irritation. She reported significant fecal urgency. There was no evidence of fecal leakage on examination, but she did need to use the restroom right before the examination. Her sphincter tone was normal. She did not have a colostomy. In January 2018, the Veteran received another VA examination. The Veteran reported needing to take Lopramide daily at least 30 minutes before meals up to 4 times per day. She reported that if she does not take the medication, she is using the restroom all day. She reported tightening of her sphincter and inability to pass any large stool. She reported use of a dilator to open her rectum. She reported abdominal pain with explosive diarrhea daily, stating that if she eats, she has to be near a toilet. She reported urgency of stool, an inability to hold it, and a need to wear incontinence briefs. She reported needing to use the bathroom 8 to 10 times before noon and blood frequently in her stool. She also reported losing weight without trying. The examiner noted that the Veteran has impairment of rectal sphincter that entailed extensive leakage, fairly frequent involuntary bowel movements, and leakage that necessitates wearing a pad. The examiner also noted she has rectal stricture that caused great reduction of lumen and extensive leakage. The examiner noted on examination the skin was raw around the anus with the appearance of frequent irritation. The Veteran was not able to tolerate rectal examination due to the tightness of her anal sphincter. In August 2019, the Veteran was seen for her anal stenosis. The physician noted a change in medication, and the Veteran now taking Loperamide and Metamucil. The Veteran reported she has the expected urgency but no longer has the incontinence and that her bowel status was in a good place. The physician noted that an anal dilatation is ill advised because the Veteran is now able to maintain continence with her medication. After review of the evidence of record, the Board finds that a rating in excess of 60 percent is not warranted. The Veteran’s fecal incontinence has only manifested to impairment of sphincter control that causes extensive leakage and fairly frequent involuntary bowel movements. The Veteran at no time has been noted as having complete loss of sphincter control. In fact, as noted above, the Veteran reported during a VA visit in August 2019 that she did not have incontinence and her bowel status was good. The August 2019 VA physician also noted that her medication controlled her incontinence. The Board acknowledges the Veteran’s assertions that she is entitled to a higher rating and that her symptoms are worse.  The Board recognizes that lay persons are competent to provide medical opinions on some medical issues.  See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011).  However, the Board has considered the Veteran’s statements and finds them credible and consistent with the rating assigned. In light of the foregoing, the Board concludes that the preponderance of evidence is against the claim and the benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 3. Entitlement to a Separate Rating: Rectal Stricture As provided above, the Board must consider disabilities related to the Veteran’s squamous cell carcinoma residuals that fall under separate diagnostic codes. During the Veteran’s January 2018 VA examination, the examiner noted that the Veteran had rectal stricture that was attributable to the diagnoses of squamous cell carcinoma residuals and/or impaired sphincter control. The examiner found that the rectal stricture caused great reduction of lumen and extensive leakage. The Board also notes that during the Veteran’s March 2010 examination, the examiner noted that the Veteran’s lumen was very small and tight of the rectum and anus. Under Diagnostic Code 7333 for Rectum and Anus Stricture, a 50 percent rating is provided for stricture that consists of great reduction of lumen or extensive leakage; and a 100 percent rating is provided for requiring of colostomy. See 38 C.F.R. § 4.114, Diagnostic Code 7333. After review of the evidence of record, the Board finds that a rating of 50 percent is warranted for rectal stricture. However, a rating in excess of 50 percent is not warranted as the Veteran has not needed a colostomy at any time during the pendency of the appeal. Thus, a separate rating of 50 percent, but no higher, for rectal stricture is warranted. The benefit of the doubt doctrine has been applied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). REASONS FOR REMAND Although the Board sincerely regrets further delay, another remand is required in order to provide the Veteran with every possible consideration. Entitlement to Service Connection: Left Hip Disability The Veteran contends that she currently suffers from a left hip disability that is related to her active service, to include as due to or aggravated by her service-connected squamous cell carcinoma of the rectum residuals. In January 2018, the Veteran was provided a VA examination. The examiner opined that the Veteran’s condition was aggravated by her service-connected rectal cancer. The examiner explained that per records and the Veteran’s report, she suffered from an infection of the left hip while undergoing radiation for rectal cancer. In January 2020, an addendum opinion was received to address the clarification that the Veteran’s infection of the left hip was actually 3 years after her radiation treatment. Due to the clarification, the examiner opined that the Veteran’s condition was less likely than not due to or aggravated by her service-connected condition. The examiner explained that VA records show the Veteran was treated for spontaneous left hip arthritis, aspirate, and strep agalactiae on cultures. The examiner explained that due to the radiation therapy being completed in 2003 and the hip infection occurring three years after in 2006, it is less likely that the left hip infection was caused by the radiation therapy. The examiner then noted that access to the Carolina healthcare system records, which may indicate what caused the infection, were not reviewed. The Board finds the opinions are inadequate to fairly adjudicate the claim. In the January 2020 addendum opinion, the examiner specifically noted that the records showing the infection treatment were not available. The Board finds that due to the Veteran contending that she was previously informed her hip condition was related to her radiation treatment, and the records from the treatment not being of record, the records need to be reviewed in order to provide an adequate opinion. Therefore, the Board finds that a remand is required in order to retrieve missing medical records and an addendum opinion considering such records. The matters are REMANDED for the following action: 1. Obtain and associate with the electronic file any outstanding VA treatment and private medical records relevant to the Veteran’s claim. Specifically, records from the Charlotte Medical Clinic showing the Veteran’s treatment for her left hip infection should be obtained. All attempts to retrieve such records should be made of record. 2. After all records have been associated with the claims file, send the claims to the examiner who provided the January 2018 and January 2020 VA opinions to determine the etiology of the Veteran’s left hip condition. If the January 2020 examiner is not available, then the file should be sent to an appropriate examiner for the requested opinion. If the examiner determines the opinion cannot be provided without examination, then such examination should be scheduled and may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic.  The record and a copy of this Remand must be made available to the examiner.     Following a review of the entire record, the Veteran’s competent lay statements, as well as the Veteran’s report regarding the onset and progression of her current symptomatology, the examiner should opine as to the following: (a) Is it at least at least as likely as not (50 percent probability or more) that the Veteran’s left hip condition is due to her service-connected rectal cancer, to include radiation treatment?     (b) Is it at least as likely as not (50 percent probability or more) that the Veteran’s left hip condition is aggravated by her service-connected rectal cancer, to include radiation treatment?  “Aggravation” is defined as any worsening beyond the natural progression of the disability.   In offering any opinion, the examiner must consider the full record, to include the lay statements regarding in-service incurrence, and the opinion should reflect such consideration.  A clearly-stated rationale for any opinion offered should be provided and must not be based solely on the lack of any in-service records.     If the examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner’s medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided.   JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Negron, 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.