Citation Nr: 21009141 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 13-28 619 DATE: February 19, 2021 ORDER Entitlement to service connection for tinnitus is granted. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to an initial disability evaluation in excess of 10 percent for a painful right knee scar is denied. Entitlement to a compensable disability rating for right knee surgical scars is denied. REMANDED Entitlement to service connection for emphysema is remanded. Entitlement to service connection for fibromyalgia, to include as secondary to post-traumatic stress disorder (PTSD) or bilateral knee disabilities, is remanded. Entitlement to an initial disability evaluation in excess of 10 percent for Eagle’s syndrome is remanded. Entitlement to an increased disability evaluation for eczema is remanded. FINDINGS OF FACT 1. Resolving all reasonable doubt in her favor, the Veteran’s tinnitus is etiologically related to service. 2. The Veteran does not have a current diagnosis of bilateral hearing loss. 3. The Veteran has one painful but not unstable scar on her right knee. 4. None of the Veteran’s linear scars on her right knee are unstable, measure at 144 square inches or greater in area, are associated with underlying soft tissue damage, or cause a limitation of function. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. § §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 3. The criteria for entitlement to an initial disability evaluation in excess of 10 percent for a painful right knee scar have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7804. 4. The criteria for entitlement to a compensable disability rating for right knee surgical scars have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes 7802, 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1989 to January 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from June 2012, February 2018, and September 2018 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2018, the Veteran testified before the undersigned at a hearing with respect to her claim for an increased initial disability evaluation for Eagle’s syndrome. A transcript of her testimony has been associated with the claims file. With respect to the claim for an increased initial disability evaluation for Eagle’s syndrome, the Board notes that the Board originally denied this claim in a June 2018 decision, which was subsequently appealed to the Court of Appeals for Veterans Claims (Court). While the matter was pending before the Court, however, the parties entered into a Joint Motion for Remand (JMR). Pursuant to the terms of the JMR, the parties agreed that the Board had erred in its April 2018 decision to the extent that it did not adequately discuss certain relevant evidence regarding the Veteran’s symptoms or consider whether an extraschedular disability rating was warranted. The Court subsequently vacated the April 2018 decision and remanded the matter to the Board for further consideration. Thereafter, the Board remanded the claim for the Director of Compensation Service to consider whether an extraschedular rating was warranted under 38 C.F.R. § 3.321(b)(1). In a November 2020 advisory opinion, the Director decided that entitlement to an extraschedular rating for Eagle’s syndrome was not warranted. Afterwards, the RO issued a December 2020 supplemental statement of the case denying the claim for an increased rating. The matter now returns to the Board. Additionally, the Board now has jurisdiction over the Veteran’s claims for service connection for fibromyalgia, to include as secondary to PTSD or bilateral knee disabilities, bilateral hearing loss, tinnitus, and emphysema, as well as claims for increased ratings for right knee scars and eczema. Service Connection Generally, the Veteran asserts that she is entitled to service connection for tinnitus and bilateral hearing loss caused by military noise exposure and that she has continuously experienced these symptoms since being on active duty. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § § 3.303; Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Presumptive service connection may be granted for “chronic diseases” if the disease manifests to a compensable degree within service or within the presumptive period of one year after separation. 38 C.F.R. § § 3.307(a)(3). Tinnitus and bilateral hearing loss are both considered to be a chronic “organic disease of the nervous system.” 38 U.S.C. § 1101; 38 C.F.R. § 3.309(a). For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Service connection may also be established under 38 C.F.R. § 3.303(b) where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may legitimately be questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection for the specific chronic diseases listed in 38 C.F.R. § 3.303(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Stated differently, the provision in 38 C.F.R. § 3.303(b) allows for a different means of establishing the nexus element of service connection by showing chronicity or continuity of symptomatology. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of the positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 1. Tinnitus Here, the Veteran has been diagnosed with tinnitus. As such, the central question for the Board is whether her tinnitus had its onset during service or is otherwise etiologically related to it. Here, the Veteran reported that she has experienced tinnitus since service and that she was exposed to loud noises while serving in the military. According to Charles v. Principi, a veteran is competent to testify to in-service acoustic trauma, in-service symptoms of tinnitus, and post-service continuous symptoms of tinnitus because ringing in the ears is capable of lay observation. 16 Vet. App. 370, 374 (2002). As such, the Board finds that the Veteran’s statement is competent and credible to establish that her symptoms of tinnitus manifested during service. As such, her statements have been afforded significant probative weight. Additionally, her lay statements are supported by the record, which confirms that her military occupational specialty, petroleum supply specialist, carried a high probability of hazardous noise exposure. Indeed, her service treatment records indicate that she was given ear plugs in October 1990 due to exposure to noise. The Veteran was afforded a VA examination in July 2018 to determine the nature and etiology of her tinnitus. In the examination report, the VA examiner opined that her tinnitus was less likely as not related to her service because, despite conceded hazardous noise exposure, there was no “noise injury” while in service. After considering the most probative lay and medical evidence of record, however, the Board affords the benefit of the doubt to the Veteran and finds that she has continuously experienced tinnitus since service. Although the VA examiner rendered a negative nexus opinion against her claim that tinnitus was caused by in-service noise exposure, the Board is not obligated to accept an examiner’s opinion. See Hayes v. Brown, 5 Vet. App. 60 (1993). To that end, the examiner’s rationale focused on the lack of shifts in the Veteran’s hearing during service. However, whether the Veteran experienced hearing loss or auditory shifts during service does not necessarily demonstrate whether she was suffering from tinnitus. Instead, the chief inquiry should be whether her tinnitus had its onset during service or is otherwise related to it, regardless of hearing loss. Indeed, the July 2018 VA examiner conceded the Veteran’s in-service noise exposure and noted that she reported that her tinnitus began in service. The Board finds that the Veteran’s lay reports regarding the onset and continuous nature of her tinnitus are both competent and credible. Resolving all reasonable doubt in her favor, the Board finds that she is thus entitled to service connection for tinnitus. 2. Hearing loss The Veteran also asserts that she has hearing loss related to her military service. As a threshold matter, the Board must first determine whether she has a current diagnosis of bilateral hearing loss for VA purposes. Under 38 C.F.R. § 3.385, hearing loss is considered a disability for VA purposes when pure tone thresholds in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC test are less than 94 percent. During her July 2018 VA audiology examination, pure tone thresholds, in decibels, were as follows for the following frequencies: 500 Hertz 1000 Hertz 2000 Hertz 3000 Hertz 4000 Hertz Right 20 15 15 10 5 Left 20 15 10 10 10 Additionally, speech audiometry revealed speech recognition ability of 94 percent and 96 percent in the right and left ear, respectively. These results indicate that the Veteran does not have a current diagnosis of bilateral hearing loss for VA purposes. First, the pure tone thresholds at 500, 1000, 2000, 3000, and 4000 are all below 40 decibels. Indeed, the highest pure tone threshold among these frequencies in either ear is 20 decibels. Additionally, the speech recognition scores in both ears are 94 percent or greater. A comparison between these findings and the criteria of 38 C.F.R. § 3.385 shows that a current hearing loss disability is simply not present. While the Board recognizes the Veteran’s sincere belief that she has hearing loss, she is not competent to provide such a diagnosis in this case. Unlike tinnitus, above, this issue requires specialized testing in accordance with VA regulations. Consequently, the Board gives more probative weight to the competent medical evidence of record, which shows no current disability for VA purposes. In the absence of evidence of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinksi, 2 Vet. App. 141 (1992). Moreover, the evidence of record does not indicate that the Veteran has been diagnosed with bilateral hearing loss for VA purposes during the pendency of his appeal or immediately prior to filing her claim. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Because this evidence does not contain any data indicating whether the Veteran satisfies the VA criteria for bilateral hearing loss, service connection for bilateral hearing loss is not warranted. 38 U.S.C. § 5107(b). Increased Rating Generally, the Veteran asserts that she is entitled to higher disability ratings for a painful scar and other surgical scars on her right knee. Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. 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. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Where, as here, entitlement to service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each piece of evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). VA is responsible for determining whether the evidence supports the claim or is relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Turning to the evidence of record, the Veteran has been afforded various VA examinations that discuss her right knee scars. First, at a July 2018 VA scars examination, her examiner noted that she had four scars on her right knee. One of these scars was painful and tender to palpation, but no scars were unstable or due to burns. All four scars were linear. The first scar, which was on her right anterior knee from the inferior thigh to the superior lower extremity, measured 23.5 centimeters, while the others on her right anterior inferomedial knee, right anterior knee, and right anterior inferior knee measured 3.5 centimeters, 4 centimeters, and 5 centimeters, respectively. None of the scars resulted in limitation of function or any other complications, conditions, signs, or symptoms associated with any scar. Additionally, the Veteran underwent a May 2019 VA knee and lower leg conditions examination. The May 2019 VA examiner noted a scar on her right knee measuring 6.5 centimeters by 0.2 centimeters, as well as a scar that was 22 centimeters in length and 0.3 centimeters wide. The May 2019 VA examiner stated that none of the scars were painful or unstable, had a total area equal to or greater than six square inches, or were located on the head, face, or neck. Last, at a separate February 2020 VA examination on knee and lower leg conditions, the February 2020 VA examiner noted that there was a vertical right knee midline scar measuring 21.5 centimeters by 0.5 centimeters, as well as a vertical right knee medial aspect scar that was 5.5 centimeters by 0.5 centimeters, a horizontal right knee superior scar that was 6.5 centimeters by 0.2 centimeters, a horizontal right knee inferior scar that was 7 centimeters by 0.2 centimeters, and a lateral right knee port site that was 1 centimeter by 0.5 centimeters. The February 2020 VA examiner indicated that none of the scars were painful or unstable, had a total area equal to or greater than six centimeters, or were located on the head, face, or neck. The scars on the Veteran’s right knee are currently rated at 10 percent and 0 percent disabling under diagnostic codes 7804 and 7802, respectively. Diagnostic code 7804 is related to unstable or painful scars, while diagnostic code 7802 is related to burn scars or scars due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. The Board notes that the Veteran’s surgical scars were originally assigned a noncompensable rating under diagnostic code 7805 from August 19, 2013, but that the diagnostic code was changed to 7802 from February 6, 2020, and that a separate 10 percent rating under diagnostic code 7804 was assigned from June 4, 2018. At the outset, the Board finds that there is no indication in the competent, credible evidence of record that any of the Veteran’s right knee scars result in limitation of function as to routine daily activities or employment. The Board has also considered whether other diagnostic criteria could potentially apply in evaluating her right knee scars but finds that no higher rating is assignable under any other diagnostic codes. There are several diagnostic codes related to scars. For instance, diagnostic code 7800 contemplates scars of the head, neck, or face. 38 C.F.R. § 4.118, Code 7800. As all the scars in this matter are located on her right knee, a compensable rating is not warranted under diagnostic code 7800 for any of the scars. Effective August 13, 2018, VA amended its regulations governing skin disabilities. VA’s intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. For applications filed on or after the effective date, only the new criteria will be applied. 83 Fed. Reg. 32592 (July 13, 2018). As the Veteran filed her claim before the August 13, 2018, effective date, the Board will consider whether either the old or new rating criteria is more favorable to her. The pre-amended diagnostic code 7801 provided disability ratings for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7801. In contrast, the amended diagnostic code 7801 contemplates burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 (August 13, 2018). Both the old and new criteria provide that a 10 percent rating is awarded when the area of the scar(s) covers at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters). A 20 percent rating is warranted when the area of the scar(s) covers at least 12 square inches (77 square centimeters) but less than 72 square inches (456 square centimeters). A 30 percent rating is warranted when the area of the scar(s) covers at least 72 square inches (456 square centimeters) but less than 144 square inches (929 square centimeters). A 40 percent rating is assigned when the area of the scar(s) covers at least 144 square inches (929 square centimeters) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7801. Note (1) to the pre-amended diagnostic code 7801 stated that a deep scar is one associated with underlying soft tissue damage. As documented in the relevant VA examination reports, however, there is no evidence that the Veteran’s scars cover an area of at least six square inches, are deep, or are associated with underlying soft tissue damage. As such, a compensable rating is not available under either version of diagnostic code 7801. Prior to August 13, 2018, diagnostic code 7802 provided rating criteria for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7802. The amended version is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802 (August 13, 2018). Both versions state that a 10 percent disability rating is warranted when the area of the scar covers 144 square inches (929 square centimeters) or greater. In this case, however, none of the Veteran’s scars are nonlinear, associated with underlying soft tissue damage, or of an area 144 square inches or greater. Accordingly, a compensable rating is not available under either version of diagnostic code 7802. Under both the old and new rating criteria, diagnostic code 7804 provides disability ratings for scars that are unstable or painful. A 10 percent rating is warranted for one or two scars that are unstable or painful, while a 20 percent rating is warranted for three or four scars that are unstable or painful. Additionally, a 30 percent rating is warranted for five or more scars that are unstable or painful. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, an additional 10 percent should be added to the evaluation based on the total number of unstable or painful scars. Note (3) states that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, Diagnostic Code 7804. Here, there is conflicting evidence in the record with respect to whether the Veteran’s right knee scars are painful. In the July 2018 VA examination report, one scar is noted to be painful, while in the May 2019 and February 2020 VA examination reports no scars were noted to be painful. Affording the benefit of the doubt to the Veteran, the Board finds that one of her scars is painful. However, she is already in receipt of a 10 percent rating based upon this scar. In order for her to be entitled to a 20 percent rating, there must be evidence that more than one scar is painful or unstable. Here, there is no probative evidence showing such. With respect to the other scars on her right knee, the Board finds that she is not entitled to a compensable rating under diagnostic code 7804, as none of the other scars are painful or unstable. Moreover, none of the evidence of record during the relevant timeframe reflects that any of the other various scars are painful or unstable. Last, under the old rating criteria, diagnostic code 7805 provided that other scars (including linear scars) and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. The Board notes that this diagnostic code is largely unchanged under the new amendments apart from the replacement of the phrase “(including linear scars)” with “and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, or 7804.” 38 C.F.R. § 4.118, Diagnostic Code 7805 (August 13, 2018). In this case, the record does not demonstrate that the Veteran’s scars are productive of any disabling effects that are not considered in a rating provided under diagnostic codes 7800-04, and, as such, a compensable rating is not available under either version of diagnostic code 7805. Based on the foregoing, the Board finds that the Veteran is not entitled to a disability rating in excess of 10 percent for the painful scar on her right knee or compensable ratings for the remaining surgical scars on her right knee. As the preponderance of the evidence is against the claim for an increased rating, the benefit-of-the-doubt rule does not apply, and the claims must be denied. REASONS FOR REMAND Service Connection 1. Fibromyalgia The Veteran also asserts that she is entitled to service connection for fibromyalgia, to include as secondary to service-connected PTSD and bilateral right and left knee disabilities. At this juncture, however, the Board cannot reach the merits of her claim, as additional remand is warranted to obtain an addendum medical opinion on the etiology of her fibromyalgia. To that end, the record contains a private medical opinion from Dr. D.V.K. stating that the Veteran has PTSD from her experiences in the military, and that her fibromyalgia symptoms were likely caused by her PTSD and knee surgeries. However, Dr. D.V.K.’s opinion on the relationship between her fibromyalgia and her other disabilities does not contain a sufficiently detailed rationale and, as such, is of limited probative value. On the other hand, the record also contains VA examiners’ opinions from February 2018 and December 2019 VA examinations. The February 2018 VA examiner opined that the Veteran’s fibromyalgia was less likely than not due to or a result of service-connected PTSD or knee disabilities. However, the February 2018 examiner focused only on whether the Veteran’s PTSD or knee conditions caused her fibromyalgia, as opposed to whether those disabilities aggravated the condition. An adequate medical opinion regarding secondary service connection must address causation and aggravation separately. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (indicating that findings of “not due to,” “not caused by,” and “not related to” a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b)). The probative value of the February 2018 VA examination is thus significantly diminished. Likewise, the probative value of the December 2019 VA examiner’s opinion is reduced because the December 2019 VA examiner’s opinion focuses on whether fibromyalgia was incurred in or otherwise related to active service. In other words, the December 2019 VA examiner’s opinion focused on direct service connection without considering all raised theories of entitlement. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). As such, remand is warranted to obtain an addendum medical opinion that contains a sufficiently detailed rationale that properly addresses all raised theories of entitlement. Additionally, the Board notes that the Veteran’s representative has submitted the text of an article entitled “Posttraumatic stress disorder in fibromyalgia syndrome: prevalence, temporal relationship between posttraumatic stress and fibromyalgia symptoms, and impact on clinical outcome,” by Winfried Häuser et al. It does not appear that this evidence was considered by either of the VA examiners. On remand, the examiner is reminded to address this evidence, as well as the other relevant evidence of record, in his opinion. 2. Emphysema The Veteran has also claimed entitlement to service connection for emphysema. Her medical records reflect a current diagnosis of emphysema, while her service treatment records reflect various complaints of productive coughs and other upper respiratory symptoms. Furthermore, both service treatment records and post-service treatment records reflect a long history of smoking cigarettes. Additionally, her private treatment records from shortly after service indicate that she reported chest pains in June 1995. See June 1995 Clinic Progress Record. Private medical records from several years ago also indicate that she has a significant history of asthma. See March 1999 Private Treatment Records. VA’s duties to assist claimants in the development of claims may include scheduling a medical examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, the record indicates that the Veteran has been treated for emphysema during the period on appeal, and that she reported symptoms such as coughing during service. Given the above evidence of record, the Board finds that remand is warranted to obtain a medical examination and opinion on the nature and etiology of her emphysema. See McLendon, 20 Vet. App. at 83-86. Increased Rating 3. Eagle’s syndrome As set forth above, the Board previously remanded the Veteran’s claim for an increased rating for Eagle’s syndrome in September 2019 for the RO to obtain an advisory opinion as to whether an extraschedular rating was warranted for her condition. The Board acknowledges that this development has been completed and, as such, remand to ensure compliance with its prior remand directives is not necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). At this juncture, however, the Board finds that additional remand is warranted to obtain a VA examination as to whether it is possible to distinguish symptoms of her service-connected Eagle’s syndrome from manifestations of non-service-connected conditions. The Veteran’s post-service treatment records document extensive treatment for Eagle’s syndrome, a condition characterized by throat and neck pain that radiates to the ear, following a tonsillectomy. At her April 2018 hearing, the Veteran described various symptoms of her Eagle’s syndrome, including difficulty swallowing, jaw aches, regurgitating food, and hoarseness. Throughout the record, she has also attributed additional symptoms, such as nausea and neck and ear pain, to Eagle’s syndrome. Confusingly, however, her post-service treatment records also reflect extensive treatment for various other non-service-connected conditions such as Barrett’s esophagus, gastroesophageal reflux disease (GERD), and temporomandibular joint (TMJ) disorder. It is unclear from the record whether certain symptoms, such as dysphagia, are manifestations of Eagle’s syndrome or, conversely, manifestations of a non-service-connected gastrointestinal disorder, such as Barrett’s esophagus. Moreover, it is unclear whether her neck and jaw pain are related to Eagle’s syndrome or instead related to a TMJ disorder. For instance, in an October 2012 private medical opinion, Dr. J.C. opined that the Veteran’s discomfort in her right neck could be attributable to a TMJ disorder, although his opinion is equivocal. The Board also notes that the most recent VA examination with respect to the severity of her Eagle’s syndrome was conducted in July 2017. At that time, the July 2017 VA examiner did not report that the Veteran suffered from any signs or symptoms of esophageal conditions, such as dysphagia. However, this finding seems inconsistent with the rest of the record, which reflects numerous complaints of signs or symptoms associated with esophageal conditions, such as dysphagia, weight loss, regurgitation, and nausea. Additionally, the July 2017 VA examiner offered no opinion as to whether the symptoms of Eagle’s syndrome could be distinguished from the manifestations of other non-service-connected conditions. As such, in the interest of assembling clear and reliable findings, remand is warranted to obtain a contemporaneous VA examination that addresses the current severity of her Eagle’s syndrome and the nature of her symptoms. If it is not possible to distinguish the effects of the Eagle’s syndrome from the effects of other non-service-connected disabilities, such as Barrett’s esophagus, GERD, and TMJ disorder, the reasonable doubt doctrine dictates that all symptoms should be attributed to service-connected Eagle’s syndrome. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). 4. Eczema Last, the Veteran claims that she is entitled to a higher disability rating for eczema. In July 2018, she was afforded a VA examination in connection with her claim for an increased rating. At that examination, the VA examiner noted that she had no visible skin conditions at that time but noted that the Veteran had submitted pictures of the rashes on her arms and neck. However, it unclear whether the VA examiner considered these photographs when completing the examination report. Moreover, it does not appear that he elicited specific information regarding the frequency, duration, characteristics, and severity of flare-ups of her skin condition. The Board thus finds that remand is necessary to schedule another VA examination on the current severity of her eczema. If possible, the examination should be scheduled during a flare-up of her eczema. See 38 U.S.C.A. § 5103A(d); Ardison v. Brown, 6 Vet. App. 405 (1994) (holding that when evidence reflects that a disability has a history of remission and recurrence, the duty to assist requires that any examination be given during an active stage of the condition). Accordingly, the matters are REMANDED for the following action: 1. After obtaining appropriate authorization, obtain and associate with the claims file all outstanding VA treatment records and all outstanding, relevant private treatment records. 2. Thereafter, arrange to obtain an addendum medical opinion from an appropriate VA examiner in connection with the Veteran’s claim for service connection for fibromyalgia. The Veteran’s claims file and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file in its entirety. After reviewing the claims file, the examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that her fibromyalgia is (a) caused, or (b) aggravated by her service-connected PTSD or bilateral knee conditions. The examiner is reminded that causation and aggravation are distinct legal concepts that must be addressed separately. “Aggravation” is defined as worsening beyond the natural progression of the disability. If her fibromyalgia is aggravated by a service-connected disability, to the extent possible, the examiner is asked to provide an opinion as to the approximate baseline level of severity of the condition before the onset of the aggravation. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner is specifically asked to consider the Veteran’s lay statements regarding the nature and onset of her fibromyalgia, Dr. D.V.K.’s opinion, and the article “Posttraumatic stress disorder in fibromyalgia syndrome: prevalence, temporal relationship between posttraumatic stress and fibromyalgia symptoms, and impact on clinical outcome,” by Winfried Häuser et al. that the Veteran submitted into the record. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. If the examiner is unable to provide an addendum opinion without performing a physical examination of the Veteran, a new examination should be scheduled to assess nature and etiology of the Veteran’s fibromyalgia. 3. Additionally, obtain a new VA examination with an appropriate VA examiner with respect to the nature and etiology of the Veteran’s emphysema. The Veteran’s claims file and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file in its entirety. After compiling a detailed history and reviewing the claims file in its entirety, the examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s emphysema had its onset during or is otherwise etiologically related to her military service. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. 4. Additionally, obtain a new VA examination with an appropriate VA examiner with respect to the severity of the Veteran’s service-connected Eagle’s syndrome. The Veteran’s claims file and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file in its entirety. The examiner is asked to compile a detailed history and review the claims file in its entirety before doing the following: (a.) Identify all relevant conditions that have been present at any time during the pendency of this appeal that are characterized by symptoms such as dysphagia, reflux, regurgitation, diarrhea, ear, neck, and jaw pain, nausea, weight loss, and only being able to eat soft or liquid foods. In doing so, the examiner is asked to consider diagnoses reflected in her treatment records such as Barrett’s esophagus, GERD, and TMJ disorder. All indicated tests and studies, such as a barium swallow test, should be performed. (b.) If possible, separate the effects of any relevant non-service-connected conditions, such as Barrett’s esophagus, GERD, and TMJ disorder, from the effects of service-connected Eagle’s syndrome. If it is not possible to distinguish between the effects of the non-service-connected conditions from the effects of the service-connected Eagle’s syndrome, the reasonable doubt doctrine dictates that all symptoms should be attributed to the Veteran’s service-connected Eagle’s syndrome. The examiner is specifically directed to consider the Veteran’s lay statements regarding her symptoms, including her April 2018 hearing testimony. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. 5. Additionally, obtain a new VA examination with an appropriate VA examiner with respect to the severity of the Veteran’s service-connected eczema. The examination should preferably be scheduled during a time when the Veteran’s eczema is symptomatic or flaring up. The Veteran’s claims file and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file in its entirety. If the examination is not conducted during a flare-up of the Veteran’s eczema, the examiner should estimate, to the extent possible, the percentage of the entire body and exposed areas affected during a flare-up based on the Veteran’s reports. The examiner should make clear that her or she has considered all procurable data (i.e., information regarding frequency, duration, characteristics, severity, and/or functional loss related to flare-ups elicited from the Veteran). If the requested opinion cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Rademacher, 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.