Citation Nr: 21006173 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 16-05 357 DATE: February 3, 2021 ORDER New and material evidence having been received, the issue of entitlement to service connection for fibromyalgia is reopened. New and material evidence having been received, the issue of entitlement to service connection for migraine headaches is reopened. Entitlement to service connection for posttraumatic stress disorder (PTSD) based on military sexual trauma (MST) is granted. Entitlement to service connection for migraine headaches is granted. REMANDED Entitlement to service connection for fibromyalgia, including a secondary to PTSD or somatic symptom disorder, is remanded. Entitlement to service connection for a left knee disability, including as secondary to a service-connected right knee disability, is remanded. Entitlement to an increased rating for a right knee disability, currently rated as noncompensable, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. An October 2014 rating decision denied the Veteran’s claim seeking service connection for fibromyalgia; the Veteran did not appeal, no new and material evidence was received within the appeals period, and the decision is final. 2. VA has received evidence since the October 2014 rating decision, which relates to the basis for the prior denial of service connection for fibromyalgia and raises a reasonable possibility of substantiating the claim. 3. An October 2014 rating decision denied the Veteran’s claim seeking service connection for migraine headaches; the Veteran did not appeal, no new and material evidence was received within the appeals period, and the decision is final. 4. VA has received evidence since the October 2014 rating decision, which relates to the basis for the prior denial of service connection for migraine headaches and raises a reasonable possibility of substantiating the claim. 5. The Veteran’s current PTSD is at least as likely as not the result of military sexual trauma. 6. A continuity of symptomatology links the Veteran’s current migraine headache disability to migraine headaches noted in service. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the claim of entitlement to service connection for fibromyalgia. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. New and material evidence has been received to reopen the claim of entitlement to service connection for migraine headaches. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.102, 3.303, 3.304, 3.310. 4. The criteria for service connection for a migraine headache disability have been met. 38 U.S.C. §§ 1131, 1132, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1977 to August 1981. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from January 2013 and April 2016 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). In June 2019, the Veteran testified at a hearing held before the undersigned. Unfortunately, a written transcript of this hearing is unavailable. In July 2020, the Veteran was notified of the unavailability of the transcript. She was offered the opportunity to schedule an additional hearing by requesting one within 30 days of the notification. The Veteran has not requested an additional hearing. In April 2020, the Veteran filed a new claim seeking service connection for somatic symptom disorder, secondary to a service-connected right knee disability. A May 2020 rating decision allowed service connection for somatic symptom disorder. The April 2020 claim also sought service connection for PTSD based on MST. However, the issue of entitlement to service connection for PTSD, initiated with an August 2012 claim, was already in appellate status. Accordingly, it is addressed below. New and Material Evidence 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for fibromyalgia 2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for migraine headaches An October 2014 rating decision denied service connection for fibromyalgia and for migraine headaches. Service connection for fibromyalgia was denied because there was no evidence fibromyalgia was onset during or otherwise causally related to the Veteran’s active service. The rating decision denied service connection for a migraine headache condition on finding this condition preexisted, and was not aggravated by, the Veteran’s active service. The Veteran did not file a notice of disagreement, and VA did not receive additional evidence regarding the claim within one year of notice of the decision. Thus, the October 2014 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 19.52, 20.1103. VA may review a previously denied claim if new and material evidence is submitted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence is defined as existing evidence not previously submitted to the VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. The Court of Appeals for Veterans Claims (Court) held the phrase “raises a reasonable possibility of establishing the claim” must be viewed as “enabling rather than precluding reopening.” Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The Court emphasized that 38 C.F.R. § 3.156 “does not require new and material evidence as to each previously unproven element of a claim.” Id. at 120. The Court further explained the provisions of 38 C.F.R. § 3.156(a) creates a “low threshold” for finding new and material evidence that is favorable to the claimant. Id. New theories of entitlement are not a basis for reopening a claim, but if evidence supporting a new theory of entitlement constitutes new and material evidence, then VA must reopen the claim. Boggs v. Peake, 520 F.3d 1330, 1336-37 (Fed. Cir. 2008). A determination of whether a previously denied claim should be reopened is a jurisdictional matter that must be addressed before the Board may consider an underlying claim. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). Therefore, regardless of the RO’s action, the Board must address the question of whether new and material evidence has been presented to reopen a claim of service connection. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Prior to the October 2014 rating decision, a June 2014 VA fibromyalgia examination was provided. The June 2014 examiner confirmed a diagnosis of fibromyalgia and depression. He observed the Veteran’s fibromyalgia was “mainly due to her depression.” In addition, a May 2014 VA headaches examination was provided. The May 2014 examiner diagnosed migraine headaches and noted the Veteran experienced migraine headaches as a child. He stated her condition had “evolved into chronic migraine, probably aggravated by psychological factors; the patient has a long history of social problems and depression.” After the final denial of these claims, an April 2020 VA PTSD examination report was associated with the claims file. The VA examiner opined somatic symptom disorder (including symptoms of depression) was proximately due to the Veteran’s service-connected right knee disability. She also observed that the Veteran met the diagnostic criteria for PTSD based on a stressor of military sexual trauma. The Board finds the April 2020 VA PTSD examination, when considered with the June 2014 VA fibromyalgia examiner’s conclusion, that fibromyalgia was due to depression, is evidence relevant to an unestablished fact (a nexus) necessary to substantiate the claim. Further, the April 2020 VA PTSD examination, when considered with the May 2014 VA migraine headache examiner’s statement, that the headache disorder was probably aggravated by psychological factors, is also evidence relevant to an unestablished fact (a nexus) necessary to substantiate the claim. Recognizing the low threshold for reopening, the Board finds new and material evidence related to the issues of entitlement to service connection for fibromyalgia and migraine headaches, has been received. See Shade, supra. Reopening is warranted. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, reasonable doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 3. Entitlement to service connection for posttraumatic stress disorder (PTSD) based on military sexual trauma (MST) Service connection for PTSD generally requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. See Cohen v. Brown, 10 Vet. App. 128, 139-43 (1997); 38 C.F.R. § 3.304(f). If PTSD is based on in-service personal assault, evidence from sources other than the claimant’s records may corroborate the account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, mental health counseling centers, hospitals or physicians; and statements from family members, roommates, fellow service members, or clergy. 38 C.F.R. § 3.304(f)(5). Additionally, evidence of behavior changes following the claimed assault may also serve as corroboration. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. Id. Here, the Veteran seeks service connection for PTSD based on MST. Her March 2014 and April 2020 statements describe instances of sexual assault and harassment which occurred during her active duty service at the U. S. Merchant Marine Academy. An April 2020 VA PTSD examination was provided. The examiner diagnosed PTSD and noted the reported MST stressor. The examiner found this stressor was sufficient to support a diagnosis of PTSD. In addition, the examiner observed, prior to the MST, the Veteran’s military personnel records showed her performance reviews were excellent. After the MST, the Veteran was reprimanded for her personal and professional behavior and cautioned about using poor judgement. The examiner concluded there had been a change in behavior which was consistent with an MST marker. Thus, the examiner has linked the reported stressor to the diagnosed PTSD and the occurrence of the stressor is corroborated. After resolving the benefit of reasonable doubt in favor of the Veteran, the Board finds PTSD is at least as likely as not the result of MST. Service connection is warranted. 38 C.F.R. § 3.304(f)(5). 4. Entitlement to service connection for migraines A Veteran is presumed to have been sound upon entry into active service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by active service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The term “noted” refers to “[o]nly such conditions as are recorded in examination reports.” 38 C.F.R. § 3.304(b). A “[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions.” 38 C.F.R. § 3.304(b)(1); see also Crowe v. Brown, 7 Vet. App. 238, 245 (1994). When no preexisting condition is noted upon examination for entry into service, a veteran is presumed to have been sound upon entry, and the burden then shifts to VA to rebut the presumption of soundness. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 C.F.R. § 3.304. To rebut the presumption of soundness under 38 U.S.C. § 1111, there must be clear and unmistakable evidence that (1) a Veteran’s disability existed prior to service, and (2) that the preexisting disability was not aggravated during service. Id. When the presumption of soundness is not rebutted, the claim must be treated as a direct service connection claim. This presumption can only be rebutted by evidence showing both the claimed disability clearly and unmistakably pre-existed service and clearly and unmistakably was not aggravated by service. 38 C.F.R. § 3.304; see also Wagner, supra. Thus, when the presumption of soundness applies, the Veteran is not required to show that a pre-existing injury or disease increased in severity during service. Id. Rather, the burden remains with VA to show by clear and unmistakable evidence that the pre-existing disease or injury was not aggravated by service. Id. VA may show a lack of aggravation if clear and unmistakable evidence establishes that there was no increase in disability during service, or that any increase in disability was due to the natural progress of the pre-existing condition. Id. If this burden is met, then the claimant is not entitled to service connection benefits. Id. On the other hand, if VA fails to show a lack of aggravation by clear and unmistakable evidence, then the presumption has not been rebutted. Id. at 1094 (holding that Congress intended to “convert aggravation claims to ones for service connection when the government fails to overcome the presumption of soundness under section 1111”). In that case, the claim will be considered as a normal claim for service connection and, if granted, no deduction for the degree of disability existing at the time of entrance will be made. Id. at 1096 (citing 38 C.F.R. § 3.322). In other words, the claim may not be denied, nor benefits deducted, on the basis of a finding that the disability in question pre-existed active service, if VA does not also meet its evidentiary burden of showing that the disability was not aggravated during service. The clear-and-unmistakable-evidence standard is a much more formidable evidentiary burden to meet than the preponderance-of-the-evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that the clear-and-unmistakable-evidence standard is more demanding than the clear-and-convincing-evidence standard, which in turn is higher than the preponderance-of-the-evidence standard). It is an “onerous” and “very demanding” evidentiary standard, requiring that the evidence be “undebatable.” See Cotant v. West, 17 Vet. App. 116, 131 (2003) (citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993)). Chronic diseases listed in 38 C.F.R. § 3.309(a) will be service connected on a presumptive basis if they manifested to a compensable degree within one year after separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Moreover, if those same diseases are noted during service, continuity of symptomatology can show chronicity and subsequent manifestations of the same disease to establish service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-99 (1997) (overruled on other grounds Walker, supra). Migraine headaches are an organic disease of the nervous system. Organic diseases of the nervous system are chronic diseases under 38 C.F.R. § 3.309(a). The Veteran’s April 1977 entrance examination includes her report of a July 1971 hospitalization for “suspected cerebral disfunction.” However, the April 1977 medical examiner noted all testing related to this hospitalization was negative and the Veteran had been well thereafter. Accordingly, the Veteran was accepted onto active service without any notation of a pre-service headache condition. The presumption of soundness attached as to any headache disability. See Wagner, supra. The Board finds VA has not rebutted this presumption as there is not clear and unmistakable evidence that the Veteran’s headaches pre-existed service. The only evidence of pre-existing headaches is the Veteran’s subjective reported history. This does not rise to the level of establishing by clear and unmistakable evidence that the Veteran had a migraine headache disability prior to active duty service. Moreover, the Board finds that as there is evidence of multiple complaints of headaches in service, to include migraine headaches, VA had not met its burden of showing by clear and unmistakable evidence that the migraine headache disability was not aggravated in service. Accordingly, the question is one of service connection and not aggravation. A May 2014 VA headache examination confirms a diagnosis of migraine headaches. The medical history portion of this examination includes the examiner’s notation of “a long history of migraine headaches,” including headaches at age 14 and a period of increasing headache severity and frequency in 1978 or 1979 (during active service). Additionally, he noted the Veteran used codeine, which was available over the counter, to treat headache pain during her active service in Bermuda. The Veteran’s service treatment records confirm multiple in-service reports of headaches (described as sinus headaches and as migraine headaches). VA treatment records include an August 2014 VA neurology note which documents the Veteran was referred to the neurology clinic for treatment of “long-term migraine headaches.” The May 2014 examination confirms a current migraine diagnosis and the service treatment records document in-service reports of migraine headaches. The remaining issue is whether a nexus is established. As noted, migraine headaches are a chronic condition which were noted in service. A nexus may be established by continuity of symptomatology. The May 2014 examination report and VA treatment records refer to the Veteran’s reports of a long history of migraine headaches.” As a layperson, the Veteran is competent to report her long history of headaches. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). These reports are credible because they are confirmed by the service treatment records and VA treatment records. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997); see also Caluza v. Brown, 7 Vet. App. 498 (1995) (VA may consider factors including interest, bias, and inconsistent statements in determining the credibility of a witness). Thus, a nexus is shown by continuity of symptomatology. See Walker, supra. The May 2014 VA examiner did not provide an opinion as to whether the Veteran’s current headaches were directly related to her in-service headaches. He observed that her childhood headaches had evolved into her current migraine condition. As explained above, the Veteran is presumed sound on entry onto active service. Accordingly, the examiner’s conclusion is not relevant to the issue at hand. Overall, the evidence of a nexus between the current migraine disability and the in-service headaches is at least in relative equipoise. Resolving reasonable doubt in favor of the Veteran, service connection for migraine headaches is granted. See Gilbert, supra. REASONS FOR REMAND 1. Entitlement to service connection for fibromyalgia, including as secondary to PTSD or somatic symptom disorder, is remanded. When there has been a determination regarding Social Security Administration (SSA) benefits, the records concerning that decision must be obtained, if relevant. Tetro v. Gober, 14 Vet. App. 100, 108-09 (2000); Murincsak v. Derwinski, 2 Vet. App. 363, 372 (1992). VA’s duty to assist requires VA to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with military service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.§ 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Service connection is established for PTSD and somatic symptom disorder with depressive and anxious features. A June 2014 VA fibromyalgia examination confirmed a diagnosis of fibromyalgia and included the examiner’s opinion that fibromyalgia “is due mainly to [the Veteran’s] depression as that is how this started in her.” This statement suggests the Veteran’s fibromyalgia may be secondary to her service-connected psychiatric conditions. However, it does not contain sufficient details for an informed evaluation of the claim. An additional opinion to evaluate whether the Veteran’s fibromyalgia is secondary to PTSD or somatic symptom disorder must be provided. See McLendon Supra. In June 2014, the Veteran reported to the VA fibromyalgia examiner that she received SSA disability payments, based in part on a diagnosis of fibromyalgia. Records associated with the Veteran’s claim for SSA benefits are relevant to this claim, they are not yet associated with the claims file, and there is no indication VA has requested the records. VA must attempt to obtain any outstanding SSA records. 2. Entitlement to service connection for a left knee disability, including as secondary to a service-connected right knee disability, is remanded. In March 2016, the Veteran filed a claim seeking service connection for a left knee disability secondary to her service-connected right knee disability. In April 2016, a VA examiner diagnosed left and right knee arthritis. His evaluation of the right knee noted abnormal range of motion and pain with weightbearing. The examiner stated the Veteran sustained a left knee fracture in July 2016 while playing with her grandchildren in the ocean. He opined that there was “no obvious connection between [the Veteran’s] right knee condition and left knee fracture.” He attributed degenerative changes in both knees to obesity and aging. Here, the examiner observed symptomatology associated with a service-connected right knee disability. However, he did not describe the interaction between the right knee symptoms and the left knee. The examiner did not provide any discussion as to whether reduced right knee range of motion and pain may have resulted in strain being placed on the left knee or may have limited the Veteran’s ability to stabilize herself and withstand injury while playing in the ocean. Accordingly, this opinion has not considered the Veteran’s complete medical history and it does not provide the analysis required to evaluate her claim. It is inadequate. See Stefl, supra. 3. Entitlement to an increased rating for a right knee disability, currently rated as noncompensable, is remanded. In August 2012, the Veteran filed a claim seeking a compensable rating for her right knee disability. In September 2012 and in April 2016, VA knee conditions examinations were provided to evaluate this claim. Private medical records associated with the claims file after these examinations include a February 2018 Community Medical Center record noting worsening right knee pain and December 2019 records from Dr. J. S. describing a right knee ablation procedure. Given that these records indicate the Veteran’s right knee condition may have worsened since her last VA examination, a new VA examination is necessary to determine the current severity of this condition. See Snuffer v. Gober, 10 Vet. App. 400 (1997). 4. Entitlement to a total disability rating based on individual unemployability During a June 2014 VA fibromyalgia examination, the Veteran reported that she received SSA disability payments based on her migraine and fibromyalgia conditions. She also reported that she had not worked since 1998. Accordingly, the issue of TDIU is raised by the record as part and parcel of her claim seeking an increased rating for a right knee disability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). As the TDIU issue is intertwined with the remanded claim discussed above, it is also remanded at this time. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Obtain the Veteran’s disability benefit records from the Social Security Administration. Document all requests for information as well as all responses in the claims file. 2. Obtain the Veteran’s VA treatment records for the period from April 2020 to the present. 3. Obtain an opinion from an appropriate clinician regarding whether the Veteran’s fibromyalgia disability is at least as likely as not (a degree of probability of 50% or higher) caused by or aggravated beyond its natural progression by her service connected PTSD or somatic symptom disorder or any symptoms (including depression) associated with these service connected psychiatric disorders. In providing this opinion, the examiner must address the significance of the June 2014 VA examiner’s statement that the Veteran’s fibromyalgia is due mainly to the Veteran’s depression. Aggravation and causation are distinct theories and must be addressed separately and independently of each other. If aggravation is found, the clinician must attempt to establish a baseline level of severity of the fibromyalgia disability prior to aggravation by a service-connected psychiatric disorder. If the clinician determines an additional examination is necessary to provide the requested opinion, schedule an examination. If feasible, schedule a telehealth examination. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected right knee disability. If feasible, schedule a telehealth examination. 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. In so doing, 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). 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. Obtain an opinion from an appropriate clinician regarding whether the Veteran’s left knee disability is at least as likely as not (a degree of probability of 50% or higher) proximately due to or aggravated beyond its natural progression by her service-connected right knee disability. The examiner should fully describe the nature of the left and right knee disabilities. He or she should also fully describe any additional strain placed on the left knee due to the right knee condition and explain whether any right knee symptoms resulted in injury to the left knee while the Veteran was playing with her grandchildren in the ocean. In evaluating secondary service connection, aggravation and causation are distinct are distinct theories and must be addressed separately and independently of each other. If aggravation is found the examiner must attempt to establish a baseline of severity of the left knee disability prior to aggravation by the service-connected right knee disability. If the examiner determines an additional in-person examination is required to provide the requested opinions, schedule an examination. If feasible, schedule a telehealth examination. 6. Provide appropriate notice and develop the issue of entitlement to a TDIU pursuant to 38 C.F.R. § 4.16. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jeanne Celtnieks 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.