Citation Nr: 21006734 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 15-13 416 DATE: February 5, 2021 ORDER Entitlement to an initial compensable rating for bilateral hearing loss prior to April 13, 2017, and a rating in excess of 10 percent thereafter is denied. Entitlement to a compensable rating for hemorrhoids is denied. REMANDED Entitlement to an initial rating in excess of 10 percent for a lumbar spine disability is remanded. Entitlement to a rating in excess of 10 percent for a right knee disability is remanded. Entitlement to a rating in excess of 10 percent for rosacea is remanded. Entitlement to a compensable rating for allergic rhinitis is remanded. FINDINGS OF FACT 1. For the period prior to April 13, 2017, the Veteran had, at worst, Level II hearing loss in the right ear, and Level I hearing loss in the left ear. 2. For the period from April 13, 2017, the Veteran had, at worst, Level IV hearing loss, bilaterally. 3. The Veteran’s hemorrhoids are found to be mild to moderate, with pain and some bleeding. CONCLUSIONS OF LAW 1. For the period prior to April 13, 2017, the criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.85, Diagnostic Code 6100. 2. Since April 13, 2017, the criteria for a rating in excess of 10 percent for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.85, Diagnostic Code 6100. 3. The criteria for a compensable rating for hemorrhoids are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7336. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1985 to August 1989, February 2003 to May 2004, and from June 2006 to October 2007. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In October 2019, the Veteran presented testimony before the undersigned Veterans Law Judge of the Board. A transcript of the hearing has been associated with the claims file. Finally, in a July 2019 rating decision, prior to certification of the appeal to the Board, the RO granted service connection for gastroesophageal reflux disease (GERD) (claimed as a stomach condition). As this represents a full grant of the benefits sought on appeal with respect to the claim of entitlement to service connection for a stomach condition, the issue is no longer on appeal Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2020). Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Bilateral hearing loss The Veteran is seeking an initial compensable rating prior to April 13, 2017 and a rating in excess of 10 percent since for his service-connected bilateral hearing loss. By way of history, the Veteran was granted a 0 percent rating for right ear hearing loss in a March 2008 rating decision, effective from October 10, 2007. He filed a claim for an increased rating for right ear hearing loss and service connection for left ear hearing loss in December 2009, both of which were denied in a September 2010 rating decision. Thereafter, the Veteran filed a claim for an increased rating for the right and service connection for the left ear in June 2011. In the September 2011 rating decision currently on appeal, the RO granted service connection for the left ear, and changed the disability to bilateral hearing loss in accordance with regulatory provisions requiring the right and left ears to be rated together under Diagnostic Code 6100, if both are service connected. This rating decision continued the 0 percent rating. Thereafter, during the pendency of this appeal, a June 2019 rating decision increased the Veteran’s disability rating for his bilateral hearing loss to 10 percent, effective from April 13, 2017, the date of a VA examination. Evaluations of bilateral hearing loss range from noncompensable (i.e., 0 percent) to 100 percent based on organic impairment of hearing acuity, as measured by a controlled speech discrimination test (Maryland CNC) and the average hearing threshold, as measured by puretone audiometric tests at the frequencies of 1,000, 2,000, 3,000 and 4,000 Hertz. The rating schedule establishes 11 auditory acuity levels designated from Level I, for essentially normal hearing acuity, through level XI for profound deafness. Under 38 C.F.R. § 4.85, Table VI (Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination) is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the puretone threshold average (vertical columns). The Roman numeral designation is located at the point where the percentage of speech discrimination and puretone average intersect. 38 C.F.R. § 4.85(b). The puretone threshold average is the sum of the puretone thresholds at 1,000, 2,000, 3,000 and 4,000 Hertz, divided by 4. This average is used in all cases to determine the Roman numeral designation for hearing impairment. 38 C.F.R. § 4.85(d). Table VII (Percentage Evaluations for Hearing Impairment) is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal rows represent the ear having the better hearing and the vertical columns the ear having the poor hearing. The percentage evaluation is located at the point where the rows and column intersect. 38 C.F.R. § 4.85(e). VA regulations also provide that, in cases of exceptional hearing loss, when the puretone thresholds at each of the four specified frequencies (1,000, 2,000, 3,000 and 4,000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or VIa, whichever results in the higher numeral. Each ear will be considered separately. 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86(b) further provide that, when the puretone threshold is 30 decibels or less at 1,000 Hertz, and 70 decibels or more at 2,000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be considered separately. Factual Background On the authorized VA audiological evaluation in December 2007, conducted in connection with the initial claim for service connection for bilateral hearing loss, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 15 25 45 LEFT 20 20 15 20 25 The average puretone threshold reading for the right and left ears was 26 and 20 decibels, respectively. Speech audiometry revealed speech recognition ability of 88 percent for the right ear and 94 percent for the left ear. Application of these pure tone threshold average levels and speech recognition ability (percentage of discrimination) using Table VI yields values of Level II hearing in the right ear and Level I hearing in the left ear. Level I and Level II correspond to a 0 percent rating pursuant to Table VII. As for any functional effect of his hearing loss on activities of daily living, the examiner did not include any in the VA examination report. Thereafter, an August 2011 VA Audiological Examination report noted the Veteran’s pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 25 35 55 LEFT 30 25 25 30 40 The average puretone threshold reading for the right ear was 35 decibels and the left ear was 30 decibels. Speech audiometry revealed speech recognition ability of 86 percent for the right ear and 94 percent for the left ear. Application of these pure tone threshold average levels and speech recognition ability (percentage of discrimination) using Table VI yields values of Level II hearing for the right ear and Level I hearing for the left ear. Level I and Level II correspond to a 0 percent rating pursuant to Table VII. As for any functional effect of his hearing loss on activities of daily living and occupation, the examiner noted it will be difficult for the Veteran to hear and understand statements and people, as well as instructions and direction from people. The Veteran was next examined by VA in an April 2017 Hearing Loss and Tinnitus Disability Benefits Questionnaire (DBQ). The VA examiner noted the Veteran’s pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 25 35 55 LEFT 25 20 25 30 40 The average puretone threshold reading for the right ear was 34 decibels and the 29 decibels in the left ear. Speech audiometry revealed speech recognition ability of 74 percent, bilaterally. Application of these pure tone threshold average levels and speech recognition ability (percentage of discrimination) using Table VI yields values of Level IV hearing, bilaterally. Level IV and Level IV correspond to a 10 percent rating pursuant to Table VII. As for any functional effect of his hearing loss on activities of daily living and occupation, the examiner noted that due to poor hearing, the Veteran states he has to get close to people so that he can hear them clearly. He also could not understand them on the phone. Consequently, he felt isolated from people because his hearing is bad. The Veteran was next examined by VA in an April 2019 Hearing Loss and Tinnitus Disability Benefits Questionnaire (DBQ). The VA examiner noted the Veteran’s pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 20 40 55 LEFT 20 20 25 35 45 The average puretone threshold reading for the right ear was 35 decibels and 31 decibels for the left ear. Speech audiometry revealed speech recognition ability of 74 percent for the right ear and 78 percent for the left ear. Application of these pure tone threshold average levels and speech recognition ability (percentage of discrimination) using Table VI yields values of Level IV in the right ear and Level III in the left ear. Level III and Level IV correspond to a 10 percent rating pursuant to Table VII. As for any functional effect of his hearing loss on activities of daily living and occupation, the Veteran reported he has to stay close to people to hear them, focuses on lips and eyes, and really has to focus on customers at work to hear them. Additionally, the Board notes there are VA and private treatment records associated with the claims file that date throughout the pendency of this appeal. However, the records do not contain any additional audiological evaluations or treatment that would warrant a higher rating for his bilateral hearing loss. Analysis Period Prior to April 13, 2017 Based on the findings of the VA examinations of record for the period prior to April 13, 2017, the Board finds that the Veteran is not entitled to a rating in excess of 0 percent for bilateral hearing loss at any point during the appeals period as he has been found to have, at worst, Level II hearing loss in the right ear and Level I hearing loss in the left ear. See December 2007 and August 2011 VA Examinations. These findings correspond to a 0 percent rating. Period From April 13, 2017 Based on the findings of the VA examinations of record for the period from April 13, 2017, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent for bilateral hearing loss at any point during the appeals period as he has been found to have, at worst, Level IV hearing loss, bilaterally. See April 2017 VA Tinnitus and Hearing Loss DBQ. These findings correspond to a 10 percent rating. The Board acknowledges the Veteran’s contention that he is entitled to a rating higher than 0 percent prior to April 13, 2017, or rating in excess of 10 percent since for his bilateral hearing loss. As noted above, the assignment of the disability rating for hearing impairment is derived from a mechanical formula based on levels of pure tone threshold average and speech discrimination. Furthermore, the Court held that “the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment”—which “are precisely the effects that VA’s audiometric tests are designed to measure’’— and that “when a claimant’s hearing loss results in an inability to hear or understand speech or to hear other sounds in various contexts, those effects are contemplated by the schedular rating criteria.” See Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017). The Board finds that the VA examinations are the most probative evidence regarding the severity of the Veteran’s bilaterally hearing loss disability for each period on appeal. The VA examinations were performed by state-licensed audiologists and included the controlled speech discrimination test using the Maryland CNC test. The Board does not discount the difficulties the Veteran states he has with his auditory acuity, as he specifically testified to during the October 2019 Board Hearing wherein, he stated he had problems hearing consonants and people. However, the Board must base its determination on the basis of the results of the audiology studies of record. Lindemann v. Principi, 3 Vet. App. 345, 349(1992). Accordingly, the Board finds entitlement to a compensable rating prior to April 13, 2017 and a rating in excess of 10 percent since for bilateral hearing loss is not warranted. As the preponderance of the evidence is against the claim, there is no doubt to resolve. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102. The claim is denied. 2. Hemorrhoids The Veteran is seeking entitlement to a compensable rating for hemorrhoids. By way of background, the RO granted service connection for this disability in a June 2008 rating decision, and assigned an initial rating of 0 percent, effective from October 10, 2007. In June 2011, the Veteran filed for an increased rating for this disability. The September 2011 rating decision on appeal continued the 0 percent rating. Therefore, the relevant temporal focus is from June 15, 2010, one year prior to the date of receipt of the claim for an increased rating. The Veteran’s hemorrhoids are evaluated under Diagnostic Code 7336. See 38 C.F.R. § 4.114. Diagnostic Code 7336 rates hemorrhoids, external or internal; mild or moderate hemorrhoids at 0 percent. Hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences are assigned a 10 percent rating. Hemorrhoids with persistent bleeding and with secondary anemia, or with fissures are assigned a maximum 20 percent rating. Id. The descriptive words “mild,” “moderate,” and “marked” as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for “equitable and just decisions.” 38 C.F.R. § 4.6. The Veteran was scheduled for a VA examination in August 2011 to assess the severity of this disability. At that time, the Veteran reported itching, a feeling of needing to empty his bowels, occasional blood, and an obstruction due to inflammation. He denied diarrhea, pain, swelling, perianal discharge, or stool leakage. The Veteran reported that his hemorrhoids reoccur frequently, and that instead of hospitalization or surgery, treatment consisted of a high fiber diet and flexible sigmoidoscopy. The examiner performed a rectal examination and found no evidence of ulceration, fissures, reduction of lumen, loss of rectal tonus, trauma, rectal bleeding, proctitis, infections spinal cord injury, protrusion or loss of sphincter control. The anal reflexes were within normal limits. Anal walls were normal, internal hemorrhoids were present, located at 6 and 11o’clock which were reducible, the hemorrhoids were small, there was no evidence of bleeding, thrombosis was absent, and there was no evidence of frequent recurrence, without evidence of redundant tissue. No evidence of rectal fistula. The Veteran was reexamined in an April 2017 VA Rectum and Anal DBQ. The examiner noted internal and external hemorrhoids. The Veteran reported that he underwent an endoscopy in May 2015 due to red blood in the stools and on the toilet paper, as well as he was also dripping bright red blood. The examiner determined the Veteran’s hemorrhoids are mild to moderate in severity, and he has small to moderate external hemorrhoids. No other physical findings were noted on examination, The Veteran was most recently examined in an April 2019 VA Rectum and Anal DBQ. The Veteran reported that his hemorrhoids are due to his constant constipation, and reported rectal hemorrhoids and polyps. The examiner determined the Veteran’s hemorrhoids are mild to moderate in severity, and he has small non-thrombotic hemorrhoids. No other physical findings were noted on examination. The VA treatment records dated throughout the pendency of the appeal are duplicative of the findings of several VA examinations noted above. As was noted in the April 2017 VA DBQ, a May 2015 VA treatment record shows the Veteran underwent an endoscopy during which, a 5 millimeter (mm) sigmoid polyp in the sigmoid colon was removed. There was scattered diverticula in the sigmoid and descending colon, mild anemia, colonic polyp, and left side diverticulosis. It was specifically noted that there was no evidence of hemorrhoids, fissures, or fistulae upon visual examination of the anus. Further, a digital rectal exam was performed revealing normal sphincter tone without obstruction or growth. No additional objective clinical findings regarding hemorrhoids were noted. The treating physician notes only painful and bleeding hemorrhoids. In fact, there is no indication in the record that the Veteran’s hemorrhoids have ever been characterized as anything other than the Veteran’s reports of pain and bleeding. See April 2015 VA Treatment Record. Based on the foregoing evidence, the Board finds that a compensable rating for the Veteran’s hemorrhoids is not warranted at any point during the appeals period. The evidence reflects that the Veteran’s hemorrhoids are characterized as mild to moderate and painful, with some bleeding. However, there is no evidence the Veteran’s hemorrhoids are characterized as large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences experienced hemorrhoid prolapse, as is required for a 10 percent rating. Further, while the Veteran does experience some bleeding when wiping or as he has reported noticing when using the restrooms, the evidence does not show secondary anemia or anal fissure, which would warrant an even higher 20 percent rating. See 38 C.F.R. § 4.114, Diagnostic Code 7336. Given such, the Veteran’s symptoms do not approximate a 20 percent rating and is appropriately rated as noncompensable. See 38 C.F.R. § 4.7, 4.21. In reaching the above conclusions, the Board has not overlooked the Veteran’s statements with regard to the severity of his hemorrhoids disability. In this regard, the Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing constipation and bleeding. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); see also October 2019 Hearing Transcript. The Veteran has provided lay evidence through written statements and during his Board Hearing throughout the course of his appeal. He is competent to provide such statements, and the Board finds that the Veteran’s statements are credible. The Veteran’s reported symptomatology has been noted in the decision above, and the Board has considered the Veteran’s reports with respect to pain and bleeding of his hemorrhoids in evaluating his assigned rating. However, the objective medical findings provided by the Veteran’s VA examination reports have been accorded greater probative weight, especially where the examiners have done actual examinations of the Veteran, to include diagnostic testing. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (“[t]he probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches... the credibility and weight to be attached to these opinions [are] within the province of the adjudicator.”). For instance, the April 2017 examiner did not only due a rectal exam, but also performed laboratory testing. The Board notes that in April 2017 examination, the examiner also diagnosed the Veteran with pruritus ani, which he considered to be a part of the Veteran’s hemorrhoids although he also noted that others may find that it is secondary to the hemorrhoids. However, even considering this additional disability, the Veteran would not be entitled a higher rating as diagnostic code 7337, requires that it be rated for the underlying condition, which is hemorrhoids. After a review of the entire record, the Board finds that the preponderance of the evidence is against the award of a compensable rating for hemorrhoids. As a preponderance of the evidence is against the award of any higher rating, the benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). REASONS FOR REMAND 3. Lumbar Spine and Right Knee Disabilities The Veteran is presently rated at 10 percent for his lumbar spine disability, pursuant to Diagnostic Code 5243-5237, and at 10 percent for his right knee disability, pursuant to Diagnostic Code 5099-5014. He is seeking entitlement to higher initial ratings for each disability. During the October 2019 Board hearing, regarding the lumbar spine, the Veteran testified that he experiences sharp pain in his back, pain when standing, and that sitting and standing aggravates his back disability. See October 2019 Board Hearing Transcript. Regarding the right knee, he also testified to pain, grinding in the right knee with weight, experiencing pressure and pain on extension, and that that sitting and standing aggravates his right knee disability. See October 2019 Board Hearing Transcript. The Board acknowledges the Veteran has been examined in December 2007, July 2008, August 2011, March 2914, and was recently examined by VA in April 2019 for each his lumbar spine and right knee disabilities. At the time of the most recent examination in April 2019, the examiner noted there was no pain on weight-bearing and no flare-ups of the back disability. See April 2019 VA Back Conditions DBQ. Similarly, during the April 2019 Knee and Lower Leg Conditions DBQ, the VA examiner reported no pain on weight-bearing and no flare-ups of the right knee disability, but did indicate pain on examination. See April 2019 VA Knee and Lower Leg Conditions DBQ. However, in light of the Veteran’s October 2019 Board hearing testimony where the Veteran clearly describes flare-ups and pain on weight-bearing for both the lumbar spine and right knee disabilities, the Board finds that the VA examinations of record are inadequate in light of the Court of Appeals for Veterans Claims (Court) cases, Correia v. McDonald, 28 Vet. App. 158, and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Finally, the April 2019 VA examiner for the lumbar spine disability noted no evidence of radiculopathy of either the right or left lower extremities. The Board notes that the Veteran was awarded separate 20 percent ratings for each right and left lower extremity radiculopathy associated with the lumbar spine disability in a June 2014 rating decision. Thus, the Board finds that this examination is also factually inaccurate and affords it limited to no probative value for rating purposes. As such, on remand, the RO must ensure that the low back VA examination complies with the requirements as set forth in both Correia and Sharp, especially in light of the Veteran’s testimony during his October 2019 Board hearing. Therefore, for the reasons noted above, the Board finds that new VA examinations are needed to ascertain the current severity and manifestations of these service connected disabilities. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 4. Rosacea The Veteran is presently rated at 10 percent for rosacea, pursuant to Diagnostic Code 7899-7806. He is seeking entitlement to a higher rating for this disability. During the October 2019 Board hearing, the Veteran testified that the severity of his skin disability “comes and goes” depending on the weather. See October 2019 Board Hearing Transcript. The Board acknowledges the Veteran was recently examined by VA in April 2019. See April 2019 VA Skin Diseases DBQ. However, given that this examination did not address any evidence of the Veteran’s reported flare-ups, the Board finds a new VA examination during an active period of his rosacea, if possible, is warranted. See Voerth v. West, 13 Vet. App. 117, 123 (1999) (holding that an examination is not required during an active phase that lasted “only for a few days out of a year”); cf. Ardison v. Brown, 6 Vet. App. at 408 (holding that an examination must be provided during an active phase that lasts weeks to months at a time). 5. Allergic Rhinitis The Veteran is presently rated at 0 percent for his allergic rhinitis, pursuant to Diagnostic Code 6522. He is seeking entitlement to a compensable rating for this disability. During the October 2019 Board hearing, the Veteran testified that he experiences nasal congestion and uses nasal spray. See October 2019 Board Hearing Transcript. The Board acknowledges the Veteran was recently examined by VA in April 2019. See April 2019 VA Sinusitis/ Rhinitis DBQ. However, no imaging tests were completed, such as x-rays or CT scans, to determine whether the Veteran is currently experiencing any nasal obstruction. Therefore, the Board finds a new VA examination is warranted. Barr v. Nicholson, 21 Vet. App. 303 (2007). The matters are REMANDED for the following action: 1. The RO is requested to conduct a comprehensive search for all relevant VA records not presently associated with the file, dating from October 2019 to the present. 2. The Veteran should be informed that he may submit pictures to document his service-connected rosacea during an active stage of the disability. 3. The Veteran should then be afforded a VA examination to ascertain the severity and manifestation of his service-connected lumbar spine disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is instructed to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (a.) The examiner should report all signs and symptoms necessary for evaluating the Veteran’s service-connected lumbar spine disability under the rating criteria. The presence of objective evidence of pain, excess fatigability, incoordination and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. (b.) The examiner should provide the range of motion in degrees for the lumbar spine. In so doing, the examiner should test the Veteran’s range of motion in active motion and passive motion, and state whether there is pain with weight-bearing and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain so in the report. (c.) The examiner shall inquire as to periods of flare-ups, and note the frequency and duration of any such flare-ups for the lumbar spine. Any additional impairment on use or during flare-ups should be described in terms of the degrees of additional range of motion lost. The examiner should specifically describe the FSD - frequency, severity, and duration of flare-ups; name the precipitating and alleviating factors; and estimate, per the veteran, to what extent, if any, such flare-ups affect functional impairment. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also REVIEW THE PRIOR DECEMBER 2007, JULY 2008, AUGUST 2011, MARCH 2014, AND APRIL 2019 VA EXAMINATIONS and provide RETROSPECTIVE OPINIONS as to the degrees of additional range of motion lost during flare-ups, if possible. If unable to provide this retrospective estimate, the examiner should state why and provide a reasoned explanation for the determination. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” (38 C.F.R. § 4.1), copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. The Veteran should be afforded a VA examination to ascertain the severity and manifestation of his service-connected right knee disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is instructed to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (a.) The examiner should report all signs and symptoms necessary for evaluating the Veteran’s service-connected right knee disability under the rating criteria. The presence of objective evidence of pain, excess fatigability, incoordination and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. (b.) The examiner should provide the range of motion in degrees for the right knee. In so doing, the examiner should test the Veteran’s range of motion in active motion and passive motion, and state whether there is pain with weight-bearing and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain so in the report. (c.) The examiner shall inquire as to periods of flare-ups, and note the frequency and duration of any such flare-ups for the right knee. Any additional impairment on use or during flare-ups should be described in terms of the degrees of additional range of motion lost. The examiner should specifically describe the FSD - frequency, severity, and duration of flare-ups; name the precipitating and alleviating factors; and estimate, per the veteran, to what extent, if any, such flare-ups affect functional impairment. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also REVIEW THE PRIOR DECEMBER 2007, JULY 2008, AUGUST 2011, MARCH 2014, AND APRIL 2019 VA EXAMINATIONS AND PROVIDE RETROSPECTIVE OPINIONS as to the degrees of additional range of motion lost during flare-ups, if possible. If unable to provide this retrospective estimate, the examiner should state why and provide a reasoned explanation for the determination. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” (38 C.F.R. § 4.1), copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. Schedule a VA examination to determine the severity of the Veteran’s service-connected skin disability. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. The examiner is asked to address ALL of the following: (a.) The examiner should report all signs and symptoms necessary for evaluating the Veteran’s service-connected skin disability under the rating criteria and those not contemplated under the rating criteria. In other words, the examiner should identify all symptoms associated with the skin disability and assess the severity of each of the symptoms associated with it. (b.) It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (c.) IF POSSIBLE, THE VA EXAMINATION SHOULD BE SCHEDULED DURING AN ACTIVE STAGE OF THE VETERAN’S SKIN DISABILITY. THE EXAMINING FACILITY SHOULD COMMUNICATE WITH THE VETERAN AS NECESSARY TO MAXIMIZE THE LIKELIHOOD OF PERFORMING AN EXAMINATION DURING AN ACTIVE STAGE. (d.) If it is not possible to schedule the Veteran for a VA examination during an active stage, the examiner’s report should include documentation of the Veteran’s symptoms based on his description of symptoms during an active stage. (e.) The examiner should describe the area(s) of the body affected by the rosacea, to include the percentage of the entire body affected, as well as the percentage of exposed area(s) affected. (f.) The examiner should specifically note whether the Veteran has been prescribed any systemic therapy, such as corticosteroids or other immunosuppressive drugs, as well as the period prescribed during the prior twelve-month period. (g.) The Veteran testified during his October 2019 Board hearing that his skin disability “comes and goes,” which the Board construes as a flare-up. Thus, the examiner should also express an opinion concerning whether there would be additional functional impairment during flare-ups. If not feasible to do so to any degree of medical certainty without resort to speculation, then the examiner must provide an explanation for why this is the case. (h.) The examiner should also specify whether the Veteran has any functional impairment associated with his skin disability, to include any impact of the disability on the Veteran’s employment. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. 6. Schedule a VA examination to determine the severity of his service-connected allergic rhinitis. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. (a.) The examiner is asked to fully describe all symptomatology and functional deficits associated with this disability pursuant to the diagnostic criteria described in 38 C.F.R. § 4.97, including Diagnostic Code 6522. (b.) The examiner is directed to ensure IMAGINING TESTS, SUCH AS X-RAYS OR A CT SCAN, ARE CONDUCTED so as to determine whether there is presently any obstruction in the nasal passage. • SPECIFICALLY OPINE AS TO WHETHER THE VETERAN'S REPORTS OF CHRONIC CONGESTION ARE CONSISTENT WITH OBSTRUCTION OF NASAL PASSAGES ON BOTH SIDES OR COMPLETE OBSTRUCTION ON ONE SIDE. SEE OCTOBER 2019 BOARD HEARING TRANSCRIPT. Any opinion expressed by the VA examiner should be accompanied by a complete rationale. If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. 7. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Berry, 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.