Citation Nr: 21023592 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 13-25 126A DATE: April 21, 2021 ORDER Entitlement to a compensable evaluation for pseudofolliculitis barbae (PFB) is denied. Entitlement to a service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. REMANDED Entitlement to service connection for a right foot disability, to include residuals of right foot plantar warts, is remanded. Entitlement to service connection for left foot arthritis is remanded. Entitlement to disability compensation under 38 U.S.C. § 1151 for a left hand disability arising from complications from anterior subcutaneous transposition of the ulnar nerve is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s PFB affects less than 5 percent of the entire body or less than 5 percent of the exposed areas affected and requires no more than topical therapy. The Veteran’s PFB is also not productive of deep acne affecting less than 40 percent of the face and neck, and did not exhibit a characteristic of disfigurement, or visible or palpable tissue loss with either gross distortion of assymetry of one feature. 2. The Veteran does not have a current diagnosis of PTSD, and his acquired psychiatric disorder is not shown to have first manifested in service or to be otherwise attributable to service. CONCLUSIONS OF LAW 1. The criteria for a compensable evaluation for PFB have not been met 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.118, Diagnostic Codes 7800, 7806, 7828. 2. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1976 to May 1982. These matters come before the Board of Veterans’ Appeals (Board) on appeal from March 2012 (right foot), August 2015 (left hand), and September 2016 (claims concerning PFB, psychiatric disorder, left foot), rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2017, the Board remanded the appeal for further development. The appeal has now returned to the Board for adjudication. The Board notes that in January 2021 correspondence, the Veteran’s representative requested an extension of 90 days before a decision was issued in order to submit outstanding records and reports. In February 2021 correspondence, the representative indicated that this was their final correspondence in support of the appeal and that they waived any remaining time to send additional evidence. Accordingly, the Board will proceed with its review of the appeal. In August 2011 correspondence, the Veteran requested that his claim be expedited due to financial hardship. He asserted that although his son and wife are working, it was not sufficient to cover their expenses. See 38 U.S.C. § 7107(b); 38 C.F.R. § 20.800(c). The record contains various past-due bills as evidence of financial hardship; however, the Board finds that this evidence does not demonstrate the kind of severe financial hardship contemplated by the regulation. 38 C.F.R. § 20.800. Therefore, the motion to advance the case on the docket based on financial hardship is denied. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.1. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where 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). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In this case, the Veteran is currently assigned a noncompensable evaluation for his pseudofolliculitis barbae (PFB), pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7899-7828 for acne. Hyphenated diagnostic codes including a diagnostic code ending in the digits “99” are used when there is no specifically applicable diagnostic code and the disability is rated by analogy. 38 C.F.R. § 4.27. The Veteran is also currently assigned a 10 percent evaluation for an elevated chin scar associated with PFB under Diagnostic Code 7800 and a 20 percent evaluation under Diagnostic Code 7804 for an unstable and painful chin scar associated with PFB. Entitlement to higher evaluations for these scars were addressed in the September 2017 Board decision, however, the Board remanded the appeal to address whether the Veteran would be entitled to separate evaluations under Diagnostic Code 7806 for dermatitis and Diagnostic Code 7800, for disfigurement of the head, face, and neck, as prior examination findings did not address VA treatment records that noted areas of hyperpigmentation and papules on the Veteran’s face. During the pendency of the appeal, the rating criteria for evaluating a skin disorder under 38 C.F.R. § 4.118 was amended effective August 13, 2018. 83 Fed. Reg. 32593 (July 13, 2018). These amendments revised Diagnostic Code 7813, to state that disabilities evaluated under this Diagnostic Code should be evaluated under the General Rating Formula for the Skin. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); VAOPGCPREC 3-2000. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran’s claim under both the old and new rating criteria, and the criteria that is more favorable to the Veteran will be applied. If the new criteria are more favorable, they will only be applied from August 13, 2018, when the regulations became effective. Under the amended criteria, the General Rating Formula for the Skin provides that a noncompensable rating is warranted where there is no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating will be warranted where there is 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 will be warranted where there is 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 will be warranted where there is 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 further provides that depending on the predominant disability, the disability could be rated instead as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805). Prior to the regulatory change effective August 13, 2018, Diagnostic Code 7813 stated that depending on the predominant disability, the disability could be rated instead as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), or dermatitis (DC 7806), depending on the predominant disability. Under DC 7806, a noncompensable evaluation is warranted for dermatitis or eczema affecting less than 5 percent of the entire body or exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent evaluation is warranted for dermatitis or eczema affecting 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; or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation is warranted for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; or, systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation is warranted for dermatitis or eczema affecting more than 40 percent of the entire body or more than 40 percent of exposed areas; or, constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Prior to the regulatory change effective August 13, 2018, under Diagnostic Code 7800, which pertains to burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck, a 10 percent evaluation is warranted for a scar with one characteristic of disfigurement. A 20 percent evaluation is assigned for scars with visible or palpable tissue loss and either gross distortion or asymmetry of two features of paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent evaluation is assigned for scars with visible or palpable tissue loss and either gross distortion or asymmetry of two features of paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent evaluation is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of three features of paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. Note (1) provides that the eight characteristics of disfigurement, for purposes of evaluation under § 4.118, are: (1) scar five or more inches (13 or more cm. in length); (2) scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). The rating criteria for Diagnostic Code 7828 did not change under the August 2018 amendments. Diagnostic Code 7828 provides that a minimal noncompensable disability rating is warranted for superficial acne (comedones, papules, pustules) of any extent. 38 C.F.R. § 4.118, DC 7828. A 10 percent disability rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or; deep acne other than on the face and neck. Id. The maximum 30 percent disability rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. Id. Additionally, consideration may be given to rating acne as disfigurement of the head, face or neck under DC 7800, or scars under DCs 7801-05 if the predominant aspect of disability. A review of the evidence of record for the relevant time period on appeal shows that the Veteran was afforded a VA examination in connection with his claim in September 2016. He reported symptoms of intermittent irritation, burning, bleeding, and scarring. The examiner noted that the Veteran’s skin conditions cause scarring, or disfigurement of the head, face, or neck and provided findings pertaining to his scars. The examiner indicated that the Veteran did not have any systemic manifestations due to any skin disease, but that he had constantly or near constantly used a topical medication. The examiner also indicated that less than 5 percent of the total body area and less than 5 percent of the exposed body area were affected. A September 2016 VA treatment record noted that the Veteran had small keloidal papules under his chin and a few comedones on the face. The examiner also noted that the Veteran had numerous scattered skin colored and erythematous papules, involving hair follicles, mostly present on bilateral cheeks and bilateral chin/anterior neck in a background of postinflammatory hyperpigmentation. He was prescribed topical creams to treat his symptoms. Acne was not noted on the examination. During a September 2019 VA examination, the examiner noted that Veteran was unable to shave and occasionally gets bumps and other findings consistent with folliculitis. The examiner noted that the Veteran had not been treated in the past 12 months with any medication, and had not had any other treatments other than systemic or topical medications in the past 12 months for any skin condition. The Veteran was noted to have visible characteristic lesions due to his PFB that affected less than 5 percent of his total body area and less than 5 percent of his exposed body area. Specifically, the examiner described these lesions as small areas of folliculitis noted in areas of the beard on both cheeks. The examiner also noted that the Veteran did not have acne, and that his PFB did not cause scarring or disfigurement of the head, face, or neck. During a November 2020 VA examination, the Veteran reported ongoing symptoms of itching and burning in his beard area with shaving, and that he relies on topical ointments to soothe his skin afterwards. The Veteran reported using an over the counter topical corticosteroid within the past 12 months for his PFB for 6 months or more, but not constantly. He had not had any other treatments or procedures other than systemic or topical medications in the past 12 months. The examiner noted that the Veteran had a skin condition without any visible characteristic lesions at the time of examination, and specified that there were no current symptoms visible in the beard area, including any evidence of skin irritation/inflammation or pustules, which covered about 4.5 percent of the total skin surface. The examiner also noted that the Veteran did not have any other skin condition, including acne, and that he did not have any skin conditions that caused scarring or disfigurement of the head, face, or neck. The Veteran presented with what was reported to be a four-day old beard, and there was no evidence of lesions, pustules, or skin irritation or inflammation. In a separate VA examination for scars and disfigurement, the examiner found that the Veteran did not have any scars anywhere on the body or any disfigurement of the head, face, or neck. The examiner noted that the Veteran’s elevated chin scar and residual scarring associated with PFB had resolved. With regard to whether the Veteran’s PFB met two or more characteristics of disfigurement under Diagnostic Code 7800, the examiner indicated that there was no evidence of scarring or disfigurement noted at the time of the examination. The examiner further explained that based on lay and medical knowledge, PFB is subject to exacerbations and remissions based on shaving patterns. Scarring can occur with more acute symptoms of the condition, but it is possible for some types of scarring to resorb over time, especially when more superficial or with application of lotions or ointments to the affected areas, which the Veteran reported. The examiner further noted that the Veteran’s records did indicate minute scarring and some hyperpigmentation, and while it was accepted that this likely was actually the case for the Veteran, these conditions were not found to be present at the time of the examination. After reviewing the evidence of record, the Board finds that a compensable evaluation is not warranted for the Veteran’s PFB for the period on appeal. The Veteran has not been shown to have deep acne affecting less than 40 percent of the face and neck. Rather, the September 2016 treatment record noted papules and a few comedones which are consistent with a noncompensable rating under Diagnostic Code 7828. Moreover, the September 2016 treatment record, as well as all of the VA examinations of record specifically noted that the Veteran did not have acne. In addition, the evidence does not show that more than 5 percent of the of total and/or exposed body area was affected by the Veteran’s PFB, and it has only been treated with topical therapy. Thus, a compensable rating under Diagnostic Code 7806 for dermatitis or eczema is not warranted. Notably, the September 2016, September 2019, and November 2020 VA examinations all document that the Veteran was treated with topical therapy. While the November 2020 VA examiner did note that the Veteran was taking a corticosteroid or other immunosuppressive medication, the examiner also specified that the medication was topical. Thus, a higher rating under Diagnostic Code 7806 for dermatitis or eczema is not warranted. The Board has considered other potentially applicable Diagnostic Codes. As previously discussed, in the September 2017 Board decision, entitlement to higher evaluations for scarring associated with the Veteran’s PFB has already been adjudicated and constitutes a final determination on the matter. Thus, the Diagnostic Codes pertaining to scars are not applicable. A higher rating under Diagnostic Code 7800 is also not warranted as the Veteran does not have any disfigurement of the head, face, or neck. The September 2019 and November 2020 VA examiners specifically noted that there was no disfigurement of the head, face, or neck. While the September 2016 VA examination did note that the Veteran had scarring, or disfigurement of the head, face, or neck, only findings pertaining to scars were noted. In addition, the evidence does not show that the Veteran’s PFB had any characteristic of disfigurement, or visible or palpable tissue loss and either gross distortion or assymetry of one feature or paired set of features. While the September 2016 VA treatment record and November 2020 VA examination note hyperpigmentation, there is no indication that such hyperpigmentation covers an area of greater than six square inches or 39 square centimeters. Notably, during the November 2020 VA examination, there was no hyperpigmentation observed. Accordingly, the Veteran has not met the criteria for a compensable evaluation for his PFB under the rating criteria that existed prior to August 13, 2018. The Board has also considered whether the Veteran would be entitled to a compensable evaluation under the new rating criteria effective from August 13, 2018, however, the September 2019 and March 2020 VA examiners clearly indicated that the Veteran’s characteristic lesions did not involve more than five percent of the entire body or exposed areas affected. In addition, as discussed above, no more than topical therapy has been used to treat the Veteran’s PFB. Thus, the Veteran would not be entitled to a compensable evaluation under the current rating criteria for skin disabilities. Thus, having considered the relevant criteria in effect prior to August 13, 2018, and the criteria in effect after August 13, 2018, the Board finds that the Veteran is not entitled to a compensable evaluation for his PFB. The Veteran and his representative have not 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). Service Connection Service connection may be granted for a current disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. §§ 3.303(d). Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including psychoses, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. 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. As psychosis is considered to be a chronic disease for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A mental disorder diagnosis must conform to the Fourth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), or, for claims received by or pending before the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014, the DSM-V (Fifth Edition). See 38 C.F.R. §§ 4.125, 4.130; 79 Fed. Reg. 45093(Aug. 4, 2014). In this case, the Veteran’s claim was certified to the Board in April 2017; therefore, the regulations pertaining to the DSM-V are for application. There are particular requirements for establishing PTSD in 38 C.F.R. § 3.304(f) that differ from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). In order to be entitled to service connection for PTSD, there must be a diagnosis of PTSD, medical evidence that establishes a link between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Lay evidence is competent to establish the presence of observable symptomatology and “may provide sufficient support for a claim of service connection.” Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination “medical in nature.” Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). A veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. See Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. See Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § § 5107 (b)). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. 38 U.S.C. §§ 1154(a); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). In June 2013 correspondence, the Veteran asserted that he served as a combat engineer and received training with weapons such as machine guns and hand grenades. He indicated that not many could handle the emotional or mental toll of this training, and that he still has memories and dreams of this training and of being on active duty. The Veteran’s DD-214, Certificate of Discharge from Active Duty, shows that he served in the Company B, 76th Engineer Battalion as a heavy construction equipment operator, and received an Overseas Service Ribbon. Service treatment records show that in a November 1975 Report of Medical History, the Veteran initially indicated that he did not know if he had any depression or excessive worry or nervous trouble, however the examiner later clarified on the report that the Veteran denied having any nervous problems. His November 1975 enlistment examination was normal for any psychiatric disorders. In a December 1981 Report of Medical History, the Veteran reported having depression and excessive worry, and nervous trouble, however in the accompanying medical examination, no psychiatric abnormalities were noted. The Veteran’s April 1982 separation examination was normal for psychiatric disabilities, and he denied having any nervous trouble or depression/excessive worry in his April 1982 Report of Medical History. In an October 2010 VA treatment record, the Veteran reported feeling increased anxiety due to issues in his marriage. In a June 2011 psychological evaluation, S.L. (initials used to protect privacy), noted that the Veteran had a diagnosis of depressive disorder. During the evaluation, with regard to his military service, the Veteran reported that he had rage because he was forced to walk after having surgery on his foot and that he was going through a lot at the time. He indicated that he had wanted to make a career out of the military, but so many things had happened, including issues pertaining to whether he was in love. In a November 2012 VA treatment record which documented a psychiatric assessment of the Veteran, the examiner noted diagnoses of anxiety and depression. The Veteran reported that his depression started in 2009 when he was laid off. He indicated that he had prior psychiatric treatment in the form of counseling with his wife for issues tied to their marriage. With regard to his military history, the Veteran denied being in combat or experiencing any trauma. He indicated that he was AWOL (absent without leave) several times due to issues involving his first wife. In a September 2013 VA mental health assessment, the Veteran reported that he sometimes feels depressed when he is overwhelmed and feels like he “can’t deal with everything.” In an April 2015 VA treatment record, the Veteran reported experiencing severe stress at home and that his anxiety was increasing. He was diagnosed with anxiety disorder and a stress reaction, and prescribed medication for his anxiety. In an August 2016 VA examination, the Veteran was diagnosed with Cannabis Use Disorder and Alcohol Use Disorder. During the examination, the Veteran reported that he drank alcohol and used hashish on a daily basis during service. The August 2016 VA examiner found that the Veteran was not experiencing a psychological diagnosis, according to the diagnostic criteria established in the DSM-V, that was first incurred, treated, diagnosed, and/or the result of his service. Rather, the Veteran was found to be experiencing a Cannabis Use Disorder and an Alcohol Use Disorder that are not the result of his service. In a February 2019 VA psychiatry service assessment, the Veteran reported that he was having life difficulties due to a recent break up. He indicated that he recently had dreams about his military experience and training as a combat engineer dealing with explosives. When describing any trauma experienced during service, he reported that he saw men lose their limbs during training. In the interpretive summary, the examiner noted that the Veteran was seeking help for life stressors and substance abuse. In a March 2019 VA treatment record, the Veteran reported that he was going through a situation that was causing him anxiety and depression, which included his relationship problems. He reported having bad dreams and then indicated that he might have PTSD due to his military service. When asked about his anxiety, he discussed having a difficult upbringing and having stressful life events, including the death of this mother in 2010 and his divorce in 2015. In a subsequent April 2019 VA treatment record, the Veteran reported that he was doing fine in terms of his depression and anxiety. In a September 2019 VA examination, the examiner found that the Veteran had diagnoses of Narcissistic Personality Disorder, Cannabis Use Disorder, and Alcohol Use Disorder. During the examination, the Veteran indicated that he should have received mental health treatment when he was discharged. The examiner noted that the Veteran’s discharge was honorable, with unsuitability-apathy, defective attitude, or inability to expand effort constructively which is consistent with a personality disorder, that is not an axis I condition like anxiety, depression, PTSD, or schizophrenia. The Veteran also repeatedly denied any traumatic events or adjustment problems during service. He described having fun during basic training and laughing at everything that happened. The September 2019 VA examiner found that the Veteran did not have a diagnosis of PTSD as the Veteran did not describe a traumatic event that meets DSM-V stressor criteria to support a diagnosis of PTSD. The examiner also found that the Veteran did not have a current diagnosis of depression as the Veteran did not meet the DSM-V criteria for any depressive disorder. In support of the opinion, the examiner included findings which included the Veteran’s frequency and severity of symptoms that support a diagnosis of depressive disorder. The examiner also found that the Veteran’s Alcohol Use Disorder and Cannabis Use Disorder were not caused by military service and not secondary to any axis I mental health condition such as depression, anxiety, PTSD, or schizophrenia. In support of this opinion, the examiner explained that the Veteran’s pattern of drinking and cannabis use was recreational and social in nature, and that he was abstinent for many years but began to drink more heavily after his divorce and the death of his mother. The examiner noted that the Veteran had resumed use of cannabis with his girlfriend recreationally. With regard to a personality disorder, the September 2019 VA examiner found that the Veteran met the full DSM-V criteria for Narcissistic Personality Disorder based on symptoms which the examiner noted in the examination report. The examiner opined that Narcissistic Personality Disorder was not caused by, related to, or the result of the Veteran’s military service, nor was it temporarily exacerbated by or permanently aggravated beyond its natural course by the Veteran’s military service. The examiner explained that medical literature indicates that personality disorders are formed in childhood or adolescence and are not caused by experiences that occur late in adulthood. Traits consistent with this personality disorder were evident in the Veteran during childhood and adolescence per his report of his pre-military psychosocial history. Finally, the September 2019 VA examiner opined that none of the Veteran’s various mental health diagnoses, including Adjustment Disorder with Mixed Mood; Adjustment Disorder with Mixed Anxiety and Depressed Mood; Depression NOS (not otherwise specified); Unspecified Depressive Disorder; Major Depressive Disorder; or Anxiety NOS, that have been diagnosed from 2010 to the present are in any way related to, or caused by, his military service. The examiner indicated that all of these diagnoses represent the same general condition, and that based upon a thorough review of VA treatment records from 2002 to 2019, it appears that the Veteran had no documented symptoms of PTSD, anxiety, or depression from 2002 to 2009. He then presented with what appears to be mild, transient, and situationally bound symptoms of anxiety and/or depression from 2010 to 2019. Further, the examiner noted that it was highly unlikely that the Veteran ever truly met the full DSM-V criteria for an actual anxiety or depressive disorder. None of the VA treatment records actually document the whole cluster of symptoms that would indicate an actual Depressive or Anxiety Disorder. Rather it appears more likely that the various diagnoses of Adjustment Disorder, with Mixed Mood or with Mixed Anxiety and Depressed Mood are more accurate diagnoses. Since 2010, the Veteran has periodically presented with mild and transient symptoms of worry, concern, dysphoria, depressed mood, and anxiety that result from current negative life events. The examiner further noted that the Veteran appears to have difficulty adjusting to various negative life events including job loss, financial troubles, the death of his mother, homelessness, divorce, and relationship stress with various girlfriends. None of these negative life events, in turn, is in any way related to military service. In rendering this opinion, the September 2019 VA examiner indicated that she had read each and every VA treatment record, and had noted each and every psychiatric diagnosis and the etiology of every diagnosis. The examination report contained a summary of and excerpts from all of the Veteran’s mental health treatment records. The September 2019 VA examiner also added that it is highly likely that the Veteran’s longstanding pattern of difficulty adjusting to negative life events is the result of the Narcissistic Personality Disorder. The examiner explained that it is not the negative life events, per se, that are causing the negative affect, but rather the Veteran’s ineffective coping with the negative events, and that this ineffective coping is consistent with Narcissistic Personality Disorder. In February 2021, the Veteran submitted a disability benefits questionnaire (DBQ) completed by a private psychologist, H.H, dated August 2017, which noted diagnoses of Unspecified Depressive Disorder, Unspecified Anxiety Disorder, and Cannabis Use Disorder. In the accompanying opinion, H.H. concluded that the Veteran’s diagnoses more likely than not began in service, continue uninterrupted to the present, and are aggravated by his service-connected disabilities. In support of the opinion, the examiner listed the various treatment records which referenced the Veteran’s mental health history and referenced medical literature, which was submitted, that details mental health symptoms within active duty servicemen. In a statement dated August 2017, which was received in February 2021, the Veteran’s sister, L.W., indicated that prior to service, the Veteran had no mental health issues. She indicated that her mother mentioned during service, that the Veteran was struggling with depression and stress and that he would cry on the phone about having too much pressure put on him. She also indicated that the Veteran came home on leave for their father’s funeral and was even more depressed because he was close to his father. The Board finds that the preponderance of the evidence establishes that the Veteran does not have a current diagnosis of PTSD, and that an acquired psychiatric disorder is not shown to have first manifested in service or to be otherwise attributable to service. The evidence of record contains both evidence in support of and against the claim. With regard to positive evidence, the Veteran has been diagnosed with Depressive Disorder, an Anxiety Disorder, and Adjustment Disorder in the VA clinical setting which has probative value. He also underwent psychological testing in August 2017 with a private psychologist who found that the Veteran met the DSM-V criteria for Unspecified Depressive Disorder, Unspecified Anxiety Disorder, and Cannabis Use Disorder. This evidence has some probative value. In contrast, the Veteran has undergone two formal VA examinations where both examiners determined that the Veteran did not meet the criteria for a diagnosis of PTSD or any other acquired psychiatric disorder, other than Cannabis or Alcohol Use Disorders and personality disorders. These opinions also have probative value. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record as every item of evidence does not have the same probative value. In cases where there are conflicting statements or opinions from medical professionals, it is within the Board’s province to weigh the probative value of those opinions. In Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993), the Court stated that the probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. So long as the Board provides an adequate reason or basis for doing so, the Board does not err by favoring one competent medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The VA benefits system does not favor the opinion of a VA examiner over a private examiner, or vice versa. See 38 U.S.C. § 5125; White v. Principi, 243 F.3d 1378, 1381 (Fed. Cir. 2001) (declining to adopt the treating physician rule for adjudicating VA benefits). Regardless of the source, an examination report must minimally meet the requirement of being sufficiently complete to be adequate for the purpose of adjudicating the claim. See 38 U.S.C. § 5125; 38 C.F.R. § 4.2. The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert’s qualifications and analytical findings. The probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. See Sklar v. Brown, 5 Vet. App. 140 (1993). A significant factor to be considered for any opinion is based on an accurate factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Although formal rules of evidence do not apply in the VA benefits system, the Court has indicated that recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the adjudicator’s decision. Rucker v. Brown, 10 Vet. App. 67, 73 (1997). Within the VA benefits system, VA medical examiners and private physicians offering medical opinions in veterans’ benefits cases are essentially considered expert witnesses. Nieves-Rodriguez, 22 Vet. App. 295 (2008). In Nieves-Rodriguez, the Court indicated that the Federal Rules of Evidence for evaluating expert medical opinion before U.S. district courts, Fed. R. Evid. 702, are important, guiding factors to be used by VA adjudicators in evaluating the probative value of a medical opinion. The factors identified in Fed. R. Evid 702 are as follows: (1) the testimony is based upon sufficient facts or data; (2) the testimony is the product of reliable principles and methods; and (3) the expert witness has applied the principles and methods reliably to the facts of the case. The Board finds that the September 2019 VA opinion substantially outweighs the clinical diagnoses found in the VA treatment records and the August 2017 private opinion. The September 2019 VA examiner reviewed each of the clinical diagnoses documented in the VA treatment records and explained that it was highly unlikely that the Veteran ever truly met the full DSM-V criteria for an actual anxiety or depressive disorder. Rather, Adjustment Disorder, with Mixed Mood or with Mixed Anxiety and Depressed Mood are more accurate diagnoses, and that since 2010, the Veteran has periodically presented with mild and transient symptoms that result from current negative life events, which are unrelated to service. This opinion is entitled to significant probative weight as it is not only based upon an interview and a mental status examination, but reflects a full understanding of the treatment history as recorded in the clinical records. The 2019 VA examiner specifically discussed the contents of the clinical records, and acknowledged the diagnoses of depression and anxiety disorders in the clinical setting. This examiner, based upon the Veteran’s documented social and employment history, documented medical history, mental status examination, behavioral observation and psychological testing, found that a current psychiatric diagnosis, other than personality and substance abuse disorders, could not be confirmed. On the other hand, the various VA clinical diagnoses of depressive and anxiety disorders appear in the context of the Veteran’s life events, which are unrelated to service. Moreover, while the Veteran reported having dreams about service and thought this might be evidence of having PTSD in February and March 2019 VA treatment records, as well as in his June 2013 statement, consistently denied experiencing any traumatic events in service during his September 2019 VA examination. Rather, he indicated that he had fun during basic training. Thus, the various VA treatment records which document diagnoses of depressive or anxiety disorders are mostly based on the Veteran’s current life events, and do not reflect an analysis of the inconsistent self-reports by the Veteran. Thus, the September 2019 VA examiner’s opinion is afforded greater probative weight. The Board has also considered the August 2017 private opinion; however, it is afforded limited probative weight as it does not contain a supporting rationale for its conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion that contains only data and conclusions without any supporting analysis is accorded no weight). While the private examiner did include references to medical literature in support of her opinion, this literature was general in nature, and does not speak to the particular facts of this case. See Wallin v. West, 11 Vet. App. 509, 514 (1998); Sacks v. West, 11 Vet. App. 314, 317 (1998). Thus, the opinion is afforded limited probative weight. The Board notes that the September 2019 VA examiner found that the Veteran had diagnoses of Narcissistic Personality Disorder, Cannabis Use Disorder, and Alcohol Use Disorder. VA compensation may not be paid for a personality disorder, as it is specifically excluded as a disease or injury within the meaning of applicable legislation providing VA compensation benefits. See 38 C.F.R. §§ 3.303 (c), 4.9. Additionally, VA law and regulations generally preclude a grant of service connection for a disability that originated due to substance abuse, as that is deemed to constitute willful misconduct on the part of the Veteran. See 38 U.S.C. § 105; 38 C.F.R. § 3.301(d); see also, VAOPGCPREC 7-99, 64 Fed. Reg. 52,375 (June 9, 1999). There is a limited exception, however, when there is clear medical evidence that the alcohol or drug abuse is secondary to a primary service-connected disability. See Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). In this case, the September 2019 VA examiner clearly indicated that the Veteran’s alcohol and cannabis use was recreational in nature and was not secondary to any axis I mental health condition such as depression, anxiety, PTSD, or schizophrenia. Therefore, the Board finds that the Veteran does not have any psychiatric disability for which service connection may be warranted. The Board acknowledges that the Veteran, and his sister, believe that he manifests an acquired psychiatric disorder such as PTSD, as a result of events during his military service. However, a lay person is not competent to self-diagnose an acquired psychiatric disorder such as PTSD. Young v. McDonald, 766 F.3d 1348, 1352-53 (Fed. Cir. 2014). As such, the Board assigns these statements little probative weight when compared to the September 2019 opinion of the trained VA psychologist that is based on interview of the Veteran, a mental status examination and complete review of the claims folder, to include prior evaluations and lay statements. Service connection may be granted on a presumptive basis for certain chronic diseases, including psychoses, if such diseases are shown to manifest to a degree of 10 percent or more within one year following the Veteran’s separation from active military service. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In this instance however, service connection for psychoses based on a presumptive basis is not warranted as the Board concludes that the Veteran does not have a credible diagnosis of any psychosis. See 38 C.F.R. § 3.384. In sum, the most probative evidence shows that the Veteran does not have PTSD and fails to show that any acquired psychiatric disorder first manifested in service or is related to service. While the Veteran is afforded the benefit of the doubt, the preponderance of evidence is against the claim and in this case, there is no doubt to resolve. Therefore, the claim must be denied. 38 U.S.C. § 5107(b). REASONS FOR REMAND Left Hand 1151 Claim The Veteran contends that he developed additional disabilities in his left hand following a left elbow ulnar nerve procedure performed at a VA facility in April 2014. In the September 2017 Board remand, the AOJ was directed to address whether the Veteran had any chronic residuals as a result of the 2014 procedure and whether the additional disability is due to carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of the VA through the treatment of the Veteran in 2014. In a September 2019 VA examination, the examiner noted diagnoses of Boutonniere deformity, mild flexion deformity of the 5th digit, and degenerative arthritis, all affecting the left hand. In the opinion provided, the examiner indicated it was less likely than not that the Veteran’s left hand condition was caused by service or the result of his ulnar nerve surgery because records showed that the Veteran had a car door injury and symptoms preceding the surgery by 9 months. The examiner then cited to treatment records documenting numbness, tingling, and weakness, affecting the left 4th and 5th fingers. The Board finds this opinion is inadequate, as the examiner did not specifically address whether the Veteran had developed any chronic residuals as a result of his ulnar nerve surgery. Specifically, the examiner had noted a diagnosis of Boutonniere deformity, but did not address if that diagnosis had also predated the ulnar nerve surgery. Accordingly, a remand is necessary to obtain an adequate opinion. Right and Left Feet The September 2017 Board remand directed the AOJ to obtain an opinion addressing whether the Veteran had a current right foot disability that resulted from service. The examiner was specifically asked to address whether the Veteran had any residuals of his in-service surgical excision of his plantar warts. In the September 2019 VA opinion obtained, the examiner found that the Veteran’s right foot plantar wart was less likely than not due to service, and that the condition had resolved. The examiner indicated that there was no objective evidence supplied to support an additional diagnosis at this time. However, on the examination, it was noted that the Veteran experienced pain around the area where his plantar wart was located. Given the Veteran’s reports of pain documented on the examination, the Board finds that the opinion obtained is inconsistent with the examination findings. Thus, a remand is necessary to obtain an addendum opinion. The September 2017 Board remand also directed the AOJ to obtain a medical opinion addressing the Veteran’s left foot arthritis. In the September 2019 VA opinion obtained, the examiner noted a January 1984 service treatment record which described left foot hallux valgus. The September 2019 VA examiner opined that the hallux valgus deformity persists and causes altered biomechanics which have caused the Veteran’s arthritis. However, the January 1984 medical record referenced is not a service treatment record, but a post-service medical record. Thus, the opinion is inadequate as it is based on an inaccurate factual premise, and a remand is required to obtain an addendum opinion. The Veteran’s claim for entitlement to TDIU is inextricably intertwined with the service connection claims on appeal as the scheduler criteria for TDIU are not met. As such, the outcome of this remand and the additional pending service connection claims may have an impact on the TDIU claim. Therefore, the Board finds that the claim for a TDIU must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). The matters are REMANDED for the following action: 1. Associate with the record any relevant, outstanding private and VA treatment records. 2. After the development specified above is completed, obtain a VA addendum opinion from a qualified examiner concerning the issue of entitlement to compensation under 38 U.S.C. § 1151 for a left hand disability resulting from an ulnar nerve procedure performed in April 2014. The claims folder shoulder be made available to and reviewed by the examiner. After reviewing the claims file, the examiner should provide answers to the following questions: (a) Did the Veteran at least as likely as not (probability of 50 percent or greater) suffer chronic additional disability as the result of the anterior subcutaneous transposition of the ulnar nerve at the left elbow, performed on April 16, 2014? In responding to this question, the medical expert is requested to identify, to the extent possible, the etiology of the Veteran’s left hand diagnoses, identified on the September 2019 VA examination, including: Boutonniere deformity, mild flexion deformity of the 5th digit, and degenerative arthritis (b) If so, was such additional disability at least as likely as not (probability of 50 percent or greater) the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of treating VA medical personnel? (c) If the Veteran did suffer additional disability as the result of treatment by VA medical personnel, but such disability was not the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of those personnel, was that disability at least as likely as not (probability of 50 percent or greater) the result of a “reasonably foreseeable” event? (d) Was the additional disability a risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures? If so, the medical expert should discuss whether the file indicates this risk was discussed with the Veteran prior to the April 16, 2014 procedure, with reference to the procedure consent form found in the medical file. A complete rationale should be provided for any opinion offered. If the medical expert feels that the requested opinion cannot be rendered without resorting to speculation, the medical expert should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the medical expert (i.e. additional facts are required, or the medical expert does not have the needed knowledge or training). 3. Forward the claims folder to a qualified examiner to obtain an addendum opinion regarding the nature and etiology of the Veteran’s right foot disability. The examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater possibility) that the Veteran has a current right foot disability that had its onset during active duty, or is otherwise etiologically related to his active duty service. In rendering the opinion, the examiner should specifically address whether the Veteran has any residuals from the in-service excision of his plantar warts, and his reports of right foot pain documented during the September 2019 VA examination. If an examination is needed, one should be scheduled. All opinions expressed must be supported by complete rationale. 4. Forward the claims folder to a qualified examiner to obtain an addendum opinion regarding the nature and etiology of the Veteran’s left foot disability. The examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater possibility) that the Veteran has a current left foot disability that had its onset during active duty, or is otherwise etiologically related to his active duty service. In rendering the opinion, the examiner should specifically address the Veteran’s diagnosis of left foot degenerative arthritis. If an examination is needed, one should be scheduled. All opinions expressed must be supported by complete rationale. 5. After the above development is complete, to the extent possible, the AOJ should readjudicate the issues on appeal. If any requested benefit is not granted, the Veteran and his representative should be provided with a supplemental statement of the case and be given an opportunity to respond before the case is returned to the Board for further review. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Saikh, 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.