Citation Nr: 21012655 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 15-41 567 DATE: March 4, 2021 ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability. 3. Entitlement to service connection for bilateral hearing loss disability. 4. Entitlement to service connection for a disability manifested by high blood pressure. 5. Entitlement to service connection for a disability manifested by vision impairment, claimed as vision problems and residuals of a head injury. 6. Entitlement to service connection for a disability manifested by dizziness. 7. Entitlement to service connection for a head injury or residuals of a head injury. 8. Entitlement to service connection for a headache disability. 9. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). 10. Entitlement to an increased initial disability rating greater than zero percent for service connected pseudo folliculitis barbae. ORDER Entitlement to an initial disability rating of 60 percent, but no higher, for service connected pseudo folliculitis barbae is granted. REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for bilateral hearing loss disability is remanded. Entitlement to service connection for a disability manifested by high blood pressure is remanded. Entitlement to service connection for a disability manifested by vision impairment, claimed as vision problems and residuals of a head injury is remanded. Entitlement to service connection for a disability manifested by dizziness is remanded. Entitlement to service connection for a head injury or residuals of a head injury is remanded. Entitlement to service connection for a headache disability is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) is remanded. FINDING OF FACT Pseudo folliculitis barbae is manifested by large, filled bumps to the face and scarring; with treatment with systemic corticosteroids or other immunosuppressive medications constant and near constantly, treatment with immune suppressive retinoids for six weeks or more, and treatment with topical cortisone constant to near constantly; and painful infections of the skin covering 20 to 40 percent of the total body area. CONCLUSION OF LAW The criteria for an initial disability rating of 60 percent, but no higher, for pseudo folliculitis barbae have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.118, Diagnostic Code (DC) 7899-7813 (2007) (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1998 to October 2007. This matter is before the Board of Veterans Appeals (Board) on appeal from August 2012, February 2013, and May 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) in January 2021. A copy of the hearing transcript has been associated with the claims file. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Court held that the scope of a mental health disability claim includes any mental health disability that could reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. The Board has recharacterized the appeal as encompassing the issue on the title page. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). The Veteran filed a June 2016 Notice of Disagreement (NOD) for the cluster of six issues included in this appeal. He requested that a VA examiner consider his lay statements regarding if the claimed conditions are related to service. Later, at the January 2021 Hearing, the Veteran through his agent described the evidence of record. He identified additional development necessary to substantiate his claims. For example, for the PTSD claim, his agent testified, “Okay, this is Carol speaking. So, Your Honor, we are just asking that the Veteran provided information to substantiate a claim that he has been through a traumatic event. And we are just asking for consideration for him to get an examination to verify he has a current condition.” See January 2021 Hearing Transcript, p. 10. The Veteran is currently located in Germany. As a first threshold issue, the Board observes that the Veteran testified regarding tinnitus and his intent to file a claim for service connection for tinnitus. A complete claim on an application form prescribed by VA regulations is required. 38 C.F.R. § 3.155. See January 2021 Hearing Transcript, p. 18. Second, as another threshold issue, the Veteran’s agent highlighted that the Veteran filed the cluster of six service connection claims from the May 2016 rating decision on the bottom of the March 2013 Notice of Disagreement (NOD). The NOD is dated March 13, 2013 and was received by VA on March 18, 2013. To the extent these claims are later granted, the RO should consider this contention and documentation in determining any effective date(s). See January 2021 Hearing Transcript, p. 18. The Veteran in this case has not referred to any other deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct. 3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant’s failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. 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 Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Increased Rating 1. Entitlement to an increased initial disability rating greater than zero percent for service connected pseudo folliculitis barbae The Board incorporates its discussion from the sections above by reference. Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability rating has not been previously staged. As discussed below, a uniform evaluation is still warranted. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). By way of background, pseudo folliculitis barbae is currently assigned a noncompensable disability rating under Diagnostic Code (DC) 7899-7813. 38 C.F.R. § 4.118. A hyphenated DC may be used to identify the proper evaluation of a disability or a residual from disease. The first DC of a hyphenated code identifies the diagnosed disease or condition. The second DC of a hyphenated code identifies the criteria in the Schedule for Rating Disabilities used to evaluate the disability. The current rating contemplates dermatitis with less than 5 percent of the exposed area affected. Next, the Board observes the regulations pertaining to rating skin disabilities were revised effective October 23, 2008 and effective August 13, 2018. 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. The rating criteria for skin disabilities were revised effective October 23, 2008; however, the change in law did not impact DC 7813. See 73 Fed. Reg. 54708 (Sept. 23, 2008). Accordingly, for the periods prior to both August 13, 2018 and October 23, 2008, effective August 30, 2002, DC 7813 provided ratings for dermatophytosis (or ringworm) in various locations on the body, including the body (tinea corporis), the head (tinea capitis), the feet (tinea pedis), the beard (tinea barbae), the nails (tinea unguium), and the inguinal area, also known as jock itch (tinea cruris). DC 7813 provides that dermatophytosis is to be rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the predominant disability. 38 C.F.R. § 4.118 (2007), (2018). Under DC 7806 prior to August 13, 2018 and October 23, 2008, a 10 percent rating is warranted when there is at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of less than six weeks during the past 12-month period. 38 C.F.R. § 4.118, DC 7806 (2007). A 30 percent rating is warranted when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected; or, when systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. In this case, DCs 7800-7805 for the periods prior to August 13, 2018 are potentially applicable. Under the rating criteria effective August 13, 2018, DC 7813 is to be rated under the General Rating Formula for the Skin. 38 C.F.R. § 4.118, DC 7813 (2018). Under this Formula, a 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is assigned with at least one of the following: characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned with at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. The General Rating Formula for the Skin also provides that the disability may be rated as disfigurement of the head, face, or neck (DC 7800), or scars (DCs 7801-7805), depending on the predominant disability. As there is an indication in the available medical evidence of record from August 13, 2018 that the Veteran has scarring and/or disfigurement on his face as a result of his service-connected skin disorder, these DCs are potentially applicable. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that under DC 7806, “systemic therapy” means “treatment pertaining to or affecting the body as a whole,” whereas topical therapy means “treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.” Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. July 14, 2017). The Federal Circuit held that although a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. By way of history, the Veteran was afforded a pair of VA examinations in January 2012. These included a VA skin Disability Benefits Questionnaire (DBQ). The VA examiner identified that dermatitis covered less than five percent of the total body area. Accompanying the VA examination and uploaded as “Third Party Correspondence” is a “Skin Examination Disability Evaluation” from Clinica Mediterranea. The examiner documented in part “periodic inflammation flares occurring with papules and pustules localized on the neck have been ineffectively treated with hot water packs, lotions, hydrocortisone, and 0,05% retinoid creams.” Next, the March 2013 Notice of Disagreement (NOD) reads in part that the Veteran’s condition is “worse than provided at the VA examination.” The Veteran reported current treatment and requested a new VA examination to support his contention. Later, in August 2016, the Veteran submitted a private VA Skin Diseases DBQ. It shows a diagnosis of pseudofolliculitis. The history shows, “Individual has been dealing with large fluid filled bumps on the face connected to service and up until present.” There was scarring or disfigurement. The Veteran used daily systemic corticosteroids or other immunosuppressive medications, constantly or near constantly. He used immunosuppressive retinoids for 6 weeks or more, but not constantly, for extreme outbreaks. He used topical corticosteroids, or cortisone, constantly or near constantly. Upon performing a physical examination, the examiner documented that the Veteran’s infections of the skin cover 20 percent to 40 percent of the total body area. Regarding the functional impact, the physician documented that the Veteran’s current employer requires him to shave and it is difficult to do based upon the pain. He wrote, “In fact, the medication used often ruins the collar of required work attire.” The physician signed the document and provided his contact information on July 26, 2016. Recently, in January 2021, the Veteran testified regarding the severity of his service-connected pseudofolliculitis barbae (PFB). The Veteran testified that he has pustules all the time that are painful. He described: My shirts are ruined whenever I have to wear a shirt. It’s just really bad. I can, and I think I read also when they denied the claim, they said, oh, it’s prevalent in African Americans. Well, for me, from my perspective, I was made to shave. I knew I had to shave. I got a profile in the military, but at the end of the day, this was service connected and it’s still a problem. It’s a bad problem. I mean, it’s embarrassing. And I’m self-conscious because people are constantly looking at my neck. And so, for me it’s a psychological thing. But I do feel that this is service connected. See January 2021 Hearing Transcript, p. 5. Regarding the January 2012 examinations, received by VA in March 2012, the Veteran’s agent commented: Now, a review of his file shows that this medical record, the C&P, and the medical record was done by the same provider. So, there is a little discrepancy on one of them stating no scarring, no symptoms. But on the other one showing that the Veteran did have a problem. So, based on that examination rating decision August 6, 2012, granted PFB at zero percent, effective 3/25/2011. The Veteran testified that he has been in Germany, so he has been taking care of the disability himself. He reported that he has flare ups and then he needs more than just this treatment. See January 2021 Hearing Transcript, pp. 6-7. In conclusion, the Veteran’s agent asserted: Yes. So, on August 24, 2016, the DBQ clearly stated the Veteran had large, filled bumps to [the] face. Noticed scarring. The treatment with systematic cortisone daily, constant and near constant. He also was treated with immune suppressive retinoids, six weeks or more. And topical cortisone, constant to near constant. And it stated that the Veteran had visible skin condition, infections of the skin, which covered 20 to 40 percent. And so, based on that DBQ, we state the Veteran should have been at least 60 percent for his skin condition. And in service he was diagnosed with PFB and dermatitis. And this irritant dermatitis from retinol A for the treatment. See January 2021 Hearing Transcript, p. 8. The Veteran contends that he is entitled to an initial compensable disability rating for service connected pseudo folliculitis barbae, currently rated under Diagnostic Code 38 C.F.R. § 4.118, DC 7813 (2018). The noncompensable evaluation contemplates less than five percent of the exposed area affected and no use of corticosteroids. In order to have a higher evaluation, there must be at least one of the following: characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A higher, 60 percent rating is assigned with at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. As described below, the most probative evidence shows that the Veteran experiences more severe impairment requiring constant treatment that is best summarized by an increased initial evaluation of 60 percent. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report symptoms of a worsening disability including filled bumps to the face, treatment with systemic cortisone therapy constant or near constantly, and six weeks or more of immunosuppressive retinoids. The Veteran is also competent to report his medical history, including what he has been told by his physician. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). His reports have been consistent over the lengthy appeals period. We find them to be credible. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Here, the most probative evidence are the Veteran’s competent lay statements and private examination results, presenting a detailed picture of the Veteran’s pseudofolliculitis barbae. His lay submissions show severe condition that includes filled bumps to the face so serious that they have repeatedly ruined his shirts. In January 2021, the Veteran testified, “My shirts are ruined whenever I have to wear a shirt. It’s just really bad. I can, and I think I read also when they denied the claim, they said, oh, it’s prevalent in African Americans. Well, for me, from my perspective, I was made to shave. I knew I had to shave. I got a profile in the military, but at the end of the day, this was service connected and it’s still a problem.” See January 2021 Hearing Transcript, p. 5. He described flare ups. Id. at p. 7. He self-medicates but reports requiring more care. The Board finds this to be highly probative. Second, turning to the examinations, the we assign substantial probative weight to the findings of the August 2016 VA examiner. The history shows, “Individual has been dealing with large fluid filled bumps on the face connected to service and up until present.” There was scarring or disfigurement. The Veteran used daily systemic corticosteroids or other immunosuppressive medications, constantly or near constantly. He used immunosuppressive retinoids for 6 weeks or more, but not constantly, for extreme outbreaks. He used topical corticosteroids, cortisone, constantly or near constantly. The examiner documented that the Veteran’s infections of the skin cover 20 percent to 40 percent of the total body area. We assign the most probative weight to this DBQ. With regard to the January 2012 medical opinion and private treatment record, they are internally inconsistent. This was raised by the Veteran’s agent at the hearing. The Veteran’s agent remarked, “So, there is a little discrepancy on one of them stating no scarring, no symptoms. But on the other one showing that the Veteran did have a problem. So, based on that examination rating decision August 6, 2012, granted PFB at zero percent, effective 3/25/2011.” Still, the Third Party Correspondence documents papules and pustules localized on the neck ineffectively treated with hot water packs, lotions, hydrocortisone, and 0.05% retinoid creams. We only assign moderate probative weight to these findings. Here, the clinical assessments from the examining physicians and credible lay statements from the Veteran demonstrate greater initial severity of PFB than the current noncompensable evaluation. The Veteran’s disability picture for pseudofolliculitis barbae is most closely approximated by an increased 60 percent initial rating based upon large, filled bumps to the face and scarring; with treatment with systemic corticosteroids or other immunosuppressive medications constant and near constantly, treatment with immune suppressive retinoids for six weeks or more, and treatment with topical cortisone constant to near constantly; and painful infections of the skin covering 20 to 40 percent of the total body area. See 38 C.F.R. § 4.118, DC 7813 (2018). Indeed, the Veteran’s January 2021 lay testimony is competent and largely consistent with the prior clinical findings. He describes difficulty completing his duties in his career due to shirt damage, and impairment due to pain. At the very least, the evidence of record is in relative equipoise as to the severity of the Veteran’s pseudofolliculitis barbae. The Veteran, his agent, and the August 2016 physician have collectively described impairment to a substantial area of the head requiring constant or near constant treatment with corticosteroids or other immunosuppressive medications. The degree of severity, resulting impairment, and treatment regimen are the central considerations under the applicable rating criteria. As far back as the January 2012 VA examinations, the Veteran has reported nodules of the neck, ineffectively treated with hydrocortisone cream at that time. Since then, his necessary treatment regimen has intensified. He testified regarding flare ups and his desire for professional treatment with medication. The Board has no reason to doubt the accuracy of his assertions. Indeed, even if any doubt exists, the benefit accrues to the Veteran. See 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 3.102 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Thus, resolving all doubt in favor of the Veteran, his pseudofolliculitis barbae disability more nearly approximates an initial rating of 60 percent under the rating criteria of DC 7813 for the entire appeals period. See 38 C.F.R. § 4.118, DC 7813 (2007), (2018). In considering the regulations prior to and from August 13, 2018, and any scarring or disfigurement, a higher disability under DCs 7800-7805 would not be warranted. Moreover, as the Veteran’s agent testified, “[W]e state the Veteran should have been at least 60 percent for his skin condition.” See January 2021 Hearing Transcript, p. 8. This 60 percent initial disability rating represents a grant of the benefit sought on appeal. Neither the Veteran nor his agent has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching this conclusion, the benefit of the doubt rule has been favorably applied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND In light of the Veteran and his agent’s contentions, a remand is necessary to ensure that the Veteran is afforded due process, and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Entitlement to service connection for a right knee disability is remanded. 2. Entitlement to service connection for a left knee disability is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the Service Treatment Records (STRs) include a Report of Medical History from separation. The Veteran endorsed knee trouble. The explanation shows, “When I went to BNCOC in 2002, my knee went out on me and I could barely walk due to the pain; right knee. As of now, both knees pop when I walk and often times there is pain. In a related Report of Medical Assessment, there is a notation, “I would like for my knee to be x-rayed to see if there is any damage.” The Veteran signed this document in March 2007. Next, the Veteran was afforded a January 2013 VA knee examination with medical opinion. The VA examiner rendered a negative nexus opinion for the left knee. The VA examiner reasoned in part, “Popping and snapping within the knee is common, and often not a symptom of any particular problem.” Next, the November 2015 Supplemental Statement of the Case (SSOC) confirmed the prior denials. It reads in part, “Pain itself is not a disability for VA purposes.” This is under both the right and left knee. The Board observes that since this was issued, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). Weeks later, in December 2015, VA received ongoing medical treatment records that include the Veteran’s time in service. On page 1 is a chronological record of medical care. It shows a problem list that includes refractive error, astigmatism, hearing loss, tinnitus, sensorineural hearing loss, and joint pain localized in the knee. For the knee, it shows in part that the Veteran felt the right knee “give out” after running. The Veteran has had intense right knee pain since 2003. Next, the Veteran was afforded an April 2017 VA knee examination with medical opinion. The VA examiner diagnosed bilateral knee strain. The VA examiner rendered a negative nexus opinion for the right knee. Recently, at the January 2021 hearing, the Veteran testified that he suffered right and left knee injuries in service. He recounted: Well, I’m pretty sure you are familiar with the military. A lot of running, and so my knees gave out on my constantly which I was running. I was a younger soldier then. And this happened to me. I failed the PT test, physical training test, because my knees gave out. And I couldn’t run. I couldn’t. A buddy had to help me across the finish line. And as of right now, today, it hurts me to climb stairs. I asked when I got out of the military, I asked them about it. They said that I did have some knee issues. And they advised against me getting surgery. I was all about getting the surgery on them. And they advised against it. I don’t know if it was because I was getting out that they didn’t want me to do it. I don’t know. I can’t speak for them. But right now, I do have problems. I can barely exercise right now. And I’m used to exercising. So, I’ve gained a significant amount of weight because I can’t move. I can walk a little bit, you know, just barely get to work. But I was active, whereas now I’m not as active. So, that’s what I, this happened in the military. Yes. See January 2021 Hearing Transcript, pp. 16-17. The Veteran confirmed that he has had knee pain ever since service. The Veteran’s agent testified that STRs show a note of right knee strain. Id. The Veteran through his agent requested a new VA examination for the knees. Here, the VA examinations do not fully address the Veteran’s theory of entitlement, and are generally inconsistent with the Veteran’s lay statements showing the presence of left and right knee disability since service. Indeed, the Veteran is competent to provide a history of knee pain. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Functional impairment due to pain now constitutes a disability even if there is no underlying diagnosis. See Saunders, supra. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (noting that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Recently, in Miller v. Wilkie, 32 Vet. App. 249 (2020), the United States Court of Appeals for Veterans Claims (Court) held that when a VA examiner fails to address relevant lay evidence, and the Board fails to find the veteran not credible or not competent to offer that lay evidence, the proper remedy is for VA to obtain a new examination. Therefore, and in light of the agent’s contentions, the Board finds that a remand for a supplemental VA examination with medical opinions is warranted. The entire claims file should be made available to the VA examiner for review. 3. Entitlement to service connection for bilateral hearing loss disability is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the Veteran was afforded a January 2012 VA audiological examination located after the aforementioned skin conditions examination. On page 4 of the examination, the VA examiner did not indicate a review of the claims file. The VA examiner indicated that she was unable to provide a medical opinion regarding the etiology of the Veteran’s hearing loss without resorting to speculation. Years later, at the January 2021 Hearing, the Veteran testified that he had a recent hearing examination at his job. He testified that his hearing loss has worsened since separation. He reported that he was diagnosed with hearing loss disability before he got out of the military. See January 2021 Hearing Transcript, pp. 12. He is competent to report what he has been told by a physician. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran’s agent requested that the Veteran be examined again for his claimed hearing loss disability. Here, as to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). “A medical opinion is adequate when it is based upon consideration of the veteran’s prior medical history and examinations and also describes the disability in sufficient detail so that the Board’s ‘evaluation of the claimed disability will be a fully informed one.’” Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, and in light of the agent’s contentions, the Board finds that a remand for supplemental VA audiological examination with medical opinion is warranted. In addition, the entire claims file should be made available to the VA examiner for review. 4. Entitlement to service connection for a disability manifested by high blood pressure is remanded. The Board incorporates its discussion from the sections above by reference. “Hypertension” refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 mm Hg systolic and 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic as reflective of hypertension. See Dorland’s Illustrated Medical Dictionary, 896 (32nd ed. 2012). Similarly, for VA rating purposes, the term “hypertension” means that the diastolic blood pressure is predominantly 90 mm Hg or greater. The term “isolated systolic hypertension” means that the systolic blood pressure is predominantly 160 mm Hg or greater with a diastolic blood pressure of less than 90 mm Hg. See 38 C.F.R. § 4.104 , DC 7101, Note (1). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. We note that hypertension as cardiovascular-renal disease is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). By way of background, the May 2016 rating decision made a partially favorable finding. “Although there is a record of treatment inservice for high blood pressure, no permanent residual or chronic disability subject to service connection is shown by the service medical records or demonstrated by evidence following service.” Next, the Veteran submitted an August 2106 VA Hypertension Disability Benefits Questionnaire (DBQ), dated in July 2106. It shows diagnosed hypertension with related blood pressure readings. However, it does not show a date of diagnosis. The examining physician rendered a two-sentence positive nexus opinion. It shows that this was based upon a review of the service records, but the rationale is limited. Next, at the January 2021 Hearing, the Veteran testified: When I was in the military on several occasions I would go to the doctor. And the doctor informed me, hey, your blood pressure is just really elevated. And at that time, I was doing a lot of running. I felt like I was doing the right thing, exercising, eating right. And so, a couple of times they had me come back to the hospital early in the morning without anything in my system, to check my blood pressure. And it was elevating off and on. And so, at that point I knew I had high blood pressure in the military. And then when I got to Washington, my doctor he diagnosed me with high blood pressure, too. And he put me on a blood pressure pill for the blood pressure. See January 2021 Hearing Transcript, p. 15. The Veteran reported taking related medication. Id. at p. 16. Here, there is some evidence of a positive nexus, but still not a medical opinion with complete rationale. With regard to interpreting in-service blood pressure readings, VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Therefore, a remand for a supplemental VA examination with medical opinion is warranted. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Entitlement to service connection for a disability manifested by vision impairment, claimed as vision problems and residuals of a head injury, is remanded. 6. Entitlement to service connection for a disability manifested by dizziness is remanded. 7. Entitlement to service connection for a head injury or residuals of a head injury is remanded. 8. Entitlement to service connection for a headache disability is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, another of the August 2016 DBQs is for headaches. It shows a medical history of the Veteran being struck in the head in service. He has since suffered from severe migraine headaches. He medicates with ibuprofen and aspirin to control the pain. The DBQ shows diagnosed migraine headaches. However, it does not show a date of diagnosis. The examining physician rendered a two-sentence positive nexus opinion. It shows that this was based upon a review of the service records, but the rationale is limited. The physician signed the document. Recently, at the January 2021 Hearing, the Veteran testified regarding an injury in service that he claims caused current headaches and other disabilities. The Veteran recounted: So, I was at a buddy’s house. And he was out of control. I think he has some mental issues going on. And you know, I was trying to defuse the situation. And the individual dragged me out and hit my head on the concrete on the way out, or whatever. And then someone, I think it was the MPs that were passing by. And they saw what happened. I was unconscious and didn’t know what happened. And the next day I woke up in the hospital. And so, then they started telling me what happened and everything. So, I had bruises to the right side of my face, my chin was all swollen. I had a lump on my head. And so that’s the nature of that situation. And I was active duty military at that time. See January 2021 Hearing Transcript, p. 14. For any vision impairment, he clarified his theory of entitlement, “Well, I’m claiming the residual for that. I mean I wear glasses. But after that situation, I started to wear glasses. But it’s residual for that. I can see somethings far, but not a lot. Like it just worsens over time. So, yes, the residuals.” Id. For these issues, there is some evidence of a positive nexus for headaches, but still not a conclusive medical opinion, and no nexus for the other claimed residuals. The other residuals are possibly due to this event in service. Therefore, a remand for VA examinations with medical opinions is warranted. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 9. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the Veteran’s DD-214 shows his Military Occupational Specialty (MOS) as a mortuary affairs specialist for 9 years and 3 months. Next, the Veteran submitted a March 2016 VA 21-0781 Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD). He describes that as a mortuary specialist, he was requested to support the Landstuhl mortuary with the autopsy and embalming of 30 deceased service members in a week’s time as they came back from war. He later experienced anxiety attacks and uncontrollable crying. He currently takes related medication and has recurring episodes. Next, the January 2020 Statement of the Case (SOC) largely focused on corroborating a combat stressor, rather than considering the Veteran’s assertions of a non-combat stressor. It also showed that the Veteran has not been diagnosed with PTSD that was caused by service. The following year, the Veteran testified regarding his experiences in service and subsequent acquired psychiatric impairment. He described: I feel that I should be service connected for PTSD because I was the mortuary (inaudible) at the peak of war. We lost so many soldiers that were my age. And I was working in the back in the preparation room. And then I was helping out. And so, I was, one day I walked in after all the work that was done. It was 30 soldiers around about my age at that time that were laid up on the morgue’s floor. And I freaked out. I had a moment there. And I had to walk away. And currently now, I’m still not getting any sleep. I drink more than I should drink just to get me through. My day, I’m up at 3 or 4 o’clock in the morning. I can’t sleep. Sometimes I miss work. See January 2021 Hearing Transcript, p. 9. The Board observes that the current record does not contain independent or objective documentation that corroborates or verifies the Veteran’s reported claimed in-service stressor and subsequent diagnosis. This is significant inasmuch as the Veteran’s alleged stressor is non-combat in nature. Next, the Board generally observes that there are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304 (f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD 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. 38 C.F.R. § 3.304 (f) and 38 C.F.R. § 4.125 (requiring PTSD diagnoses to conform to the DSM-4/5). VA regulations require evaluation of mental disorders using the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-V). 38 C.F.R. §§ 4.125, 4.126. Here, we acknowledge the Veteran’s service during the Persian Gulf War era, and varying evidence of behavioral changes after separation. Nevertheless, additional development is necessary to satisfy the specific statutory requirements. 38 C.F.R. § 3.304 (f). There is incomplete evidence regarding the diagnosis of any acquired psychiatric disorder, including claimed PTSD, and its possible relationship to the claimed in-service stressor. For PTSD, there are essentially two avenues for entitlement: a link, established by medical evidence, between current symptoms verified in-service stressors, and/or a VA psychiatrist or psychologist confirming that the claimed stressor(s) is/are adequate to support a diagnosis of PTSD pursuant to 38 C.F.R. § 3.304 (f)(3). We will address each theory of entitlement below. First, there are currently no corroborated stressors linked to the claimed PTSD that the Veteran through his agent recently highlighted. Even so, a possible diagnosis of PTSD alone is not sufficient to establish service connection for PTSD. Indeed, 38 C.F.R. §§ 3.304 (f) and 4.125 (a) require not only a diagnosis, but also credible supporting evidence that the claimed in-service stressor occurred, in other words, corroborated stressor(s), and a link between the current symptomatology and the claimed in-service stressor(s). For this Veteran, service connection for PTSD may not be granted in the absence of a verified stressor. If there is no combat experience, there must be independent evidence to corroborate the Veteran’s statements as to the occurrence of a claimed stressor. Doran v. Brown, 6 Vet. App. 283, 288-89 (1994). A Veteran’s testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor. Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of a claimed in-service stressor. Cohen v. Brown, 10 Vet. App. 128, 142 (1997); Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996). On remand, the Veteran will once again be afforded the opportunity to assist VA in fully developing his claim. Consequently, a new notification letter should be provided to the Veteran which details requirements pertaining to his claim to service connection for PTSD based on non-combat stressor described in the March 2016, VA 21-0781. He should include all details of his unit, base, and date of the incidents, to the extent possible. This includes completion of a supplemental VA Form 21-0781 Statement in Support of Claim for Service Connection for PTSD with any additional information he is able to provide. After a thorough review of the record, the Board is cognizant that the Veteran has reported ongoing impairment including crying, missing work, and treatment with medication. He has provided descriptions of his experiences in service. There is some evidence of a positive nexus by way of his lay assertions regarding the timing of the onset and what he thinks about when he experiences psychiatric episodes. Following this corroboration of the in-service events, to the extent possible, the Veteran should be afforded a VA examination that that addresses the Veteran’s contentions as they relate to any diagnosed acquired psychiatric disorder, including PTSD. A nexus opinion should also be rendered for any other diagnoses, such as any depressive or anxiety disorder. The matters are REMANDED for the following action: 1. If the Veteran identifies other evidence, obtain updated copies of the Veteran’s VA treatment records, and associate them with the Veteran’s claims folder. 2. Issue to the Veteran and his agent a request that he submit a new stressor statement on a VA Form 21-0781 Statement in Support of Claim for Service Connection for PTSD providing any additional details he can recall regarding his claimed in-service stressor. Then, in light of the Veteran’s written statements, supra, make one more attempt to corroborate the Veteran’s claimed in-service stressor, including working on the autopsy and embalming of 30 deceased service members in one week’s period. 3. Contact the Veteran and his agent to determine his current location for the purposes of scheduling the VA examinations below. The Veteran testified that he will be working in Germany for the next couple of years. 4. Please schedule the Veteran for a VA examination to determine the nature and etiology of any left and right knee disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. Attention is invited to the STRs from separation showing knee complaints. The examiner should provide a rationale for all opinions expressed. 5. Please schedule the Veteran for an examination by an appropriate clinician to determine the nature, etiology, and severity of the Veteran’s claimed bilateral hearing loss disability. Any audiometric testing results from the examination should be associated with the claims file. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including work as mortuary affairs specialist. 6. Please schedule the Veteran for a VA examination to determine the nature and etiology of any hypertension, claimed as high blood pressure. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. Attention is invited to the August 2016 Hypertension Disability Benefits Questionnaire (DBQ). The examiner should provide a rationale for all opinions expressed. 7. Please schedule the Veteran for a VA examination to determine the nature and etiology of any disability manifested by vision impairment claimed as residuals of a head injury, disability manifested by dizziness, residuals of a head injury, and/ or headaches disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. Attention is invited to the August 2016 Headaches Disability Benefits Questionnaire (DBQ). The examiner should provide a rationale for all opinions expressed. 8. After the development noted above has been completed, schedule the Veteran for a VA psychiatric examination with a VA psychiatrist or psychologist, or acceptable VA contractor, to determine the nature and etiology of any post-traumatic stress disorder (PTSD). Correspond with his agent as necessary in light of the Veteran’s location in Germany. After reviewing the file, eliciting a history directly from the Veteran, and conducting a thorough examination, as well as any necessary diagnostic studies, the VA psychiatrist or psychologist should offer an opinion as to the following: (i) What are the Veteran’s current psychiatric disorders? In particular, has the Veteran had PTSD at any time during the appeal period? (ii) Is it at least as likely as not (a probability of 50 percent or greater) that a diagnosed non-PTSD psychiatric disorder – including any depressive or anxiety disorder – began in service, was caused by service, or is otherwise related to active service? (iii) If PTSD is diagnosed pursuant to the DSM-V, the examiner should opine on whether any of the Veteran’s claimed in-service stressor(s) has been verified (corroborated) by independent evidence, whether a verified in-service stressor is adequate to support a diagnosis of PTSD, and whether the current PTSD symptoms relate to the stressor(s). Attention is invited to the January 2021 Hearing testimony detailing behavioral changes following stressful events in service on page 9. All opinions provided must be thoroughly explained, and a complete and detailed rationale for any conclusions reached should be provided (a bare conclusory statement will be deemed inadequate). The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. It is not sufficient to base an opinion on a mere lack of documentation of complaints in the service or post-service treatment records. 9. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. The Board notes the cluster of six service connection claims from the May 2016 rating decision were first filed using the bottom of the March 2013 Notice of Disagreement (NOD). In other words, these service connection claims were dated March 13, 2013 and received by VA on March 18, 2013. If any benefits sought are not granted, issue the Veteran and his agent an appropriate supplemental statement of the case (SSOC). Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Bodi, 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.