Citation Nr: 21027292 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 19-15 637 DATE: May 5, 2021 ORDER New and material evidence not having been received, the application to reopen the claim of entitlement to service connection for hypothyroidism is denied. Prior to June 19, 2012, an initial rating of 30 percent, but no higher, for anxiety disorder with primary insomnia and depressive disorder is granted, subject to the laws and regulations governing the payment of monetary awards. As of June 19, 2012, an initial rating in excess of 50 percent for anxiety disorder with primary insomnia and depressive disorder is denied. REMANDED Entitlement to service connection for an allergy to diphenylguanidine is remanded. FINDINGS OF FACT 1. In a final rating decision issued in June 2010, the Agency of Original Jurisdiction (AOJ) denied service connection for hypothyroidism. 2. Evidence added to the record since the final June 2010 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for hypothyroidism. 3. Prior to June 19, 2012, the Veteran's anxiety disorder with primary insomnia and depressive disorder was manifested by psychiatric symptomatology resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 4. As of June 19, 2012, the Veteran's anxiety disorder with primary insomnia and depressive disorder is manifested by psychiatric symptomatology resulting in occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. CONCLUSIONS OF LAW 1. The June 2010 rating decision that denied service connection for hypothyroidism is final. 38 U.S.C. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2009). 2. New and material evidence has not been received to reopen a claim of entitlement to service connection for hypothyroidism. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. Prior to June 19, 2012, the criteria for an initial rating of 30 percent, but no higher, for anxiety disorder with primary insomnia and depressive disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9413. 4. As of June 19, 2012, the criteria for an initial rating in excess of 50 percent for anxiety disorder with primary insomnia and depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9413. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1977 to February 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in June 2010 and April 2017 by a Department of Veterans Affairs (VA) Regional Office. In August 2019, the Board remanded the claims for a higher initial rating for the Veteran's psychiatric disability and entitlement to service connection for an allergy to diphenylguanidine for additional development. In March 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge as to all issues on appeal. A transcript of the hearing has been associated with the record and, in February 2021, he was provided with his requested copy of it. At the time of the March 2020 Board hearing, the Veteran waived AOJ consideration of the evidence associated with the record since the issuance of the August 2012 statement of the case and December 2019 supplemental statement of the case. 38 C.F.R. § 20.1305(c). However, subsequent to the hearing and the issuance of the March 2021 supplemental statement of the case addressing the Veteran's claims for a higher initial rating for his psychiatric disability and service connection for an allergy to diphenylguanidine, additional evidence has been associated with the record. Nevertheless, as such is irrelevant to the issues adjudicated herein, there is no prejudice to the Veteran in the Board proceeding with an adjudication of such claims at the present time. Id. Further, the AOJ will have the opportunity to consider such newly received evidence in the readjudication of the Veteran's claim for service connection for an allergy to diphenylguanidine, which is remanded herein. 1. Whether new and material evidence has been received in order to reopen the claim of entitlement to service connection for hypothyroidism. By way of background, VA received the Veteran's original claim for service connection for hypothyroidism in January 2010. In a June 2010 rating decision, the AOJ considered the Veteran's service treatment records (STRs), post-service VA treatment records, and an April 2010 VA examination. In this regard, the AOJ noted that the Veteran's STRs revealed a notation of subclinical hypothyroidism in May 2001; however, the thyroid was normal in size on examination and no treatment was necessary. The remainder of the STRs and post-service treatment records failed to reveal a diagnosis of hypothyroidism, and the April 2010 VA examination was negative for such a diagnosis as the hemic and lymphatic systems were normal with no symptoms, the endocrine system was normal with no evidence of neck mass/nodule, lid lag, or exophthalmoses, and energy levels were normal. Further, the examiner found that the Veteran was euthyroid based on current and past test results with only one episode of an abnormal test. Consequently, the AOJ found that there was no evidence of a chronic disability related to the Veteran's military service, and denied service connection for hypothyroidism. Later that month, the Veteran was advised of the decision and of his appellate rights, but he did not enter a notice of disagreement with such decision. Additionally, no new and material evidence was physically or constructively associated with the record within one year of the issuance of such decision and, while additional service department records have since been received, none are relevant to the instant claim. Therefore, the June 2010 rating decision is final. 38 U.S.C. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2009). Generally, a claim which has been denied in an unappealed Board decision or an unappealed AOJ decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104 (b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). New evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Following the issuance of the June 2010 decision, additional evidence consisting of additional VA and private treatment records, a March 2017 VA examination, and the Veteran's lay statements, to include his testimony at the March 2020 Board hearing, was received. In this regard, such evidence reflects a current diagnosis of hypothyroidism and the Veteran's lay reports that he has experienced symptoms that he believes are related to such diagnosis, to include long-term constipation, dry skin, hair loss, weight gain, and nerve problems, during and since service. However, while subclinical hypothyroidism, as well as complaints of the aforementioned symptoms, were noted in the Veteran's STRs, to include in May 2001, and he reported seeing an endocrinologist who recommended further monitoring in order to determine whether thyroid medication was indicated, subsequent treatment records are negative for a diagnosis or treatment for a thyroid disorder as he had a normal functioning thyroid gland and follow-up testing revealed normal serum thyroid-stimulating hormone (TSH) levels until August 2016 when hypothyroidism was diagnosed. Furthermore, in March 2017, following an interview with the Veteran, a review of the record, and a physical examination, a VA examiner opined that it was less likely than not that the Veteran's currently diagnosed hypothyroidism was related to his military service. In this regard, he noted the diagnosis of subclinical hypothyroidism in service in May 2001, but, as intermittent laboratory findings were more often than not normal, such diagnosis was not supported. Furthermore, since such time, many of his laboratory findings were normal and he was never treated for a thyroid disorder. The examiner also noted the Veteran's reported subjective symptoms he claimed were related to hypothyroidism, but found that such were present for years before a thyroid disorder was suspected and many were attributed to other diagnosed disorders. Consequently, the examiner found that there was no continuity of abnormal laboratory findings on a consistent basis so as to relate the Veteran's current hypothyroidism to his military service. Rather, he opined that it was more likely than not that such disorder was related to aging than the subclinical hypothyroidism preliminarily diagnosed during military service. As noted previously, the Veteran's claim for service connection for hypothyroidism was originally denied in the June 2010 rating decision based on the lack of a current chronic disability related to his military service, and the evidence received since such rating decision likewise fails to show a relationship between the Veteran's hypothyroidism and his military service. Consequently, the Board finds the evidence added to the record since the final June 2010 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran's claim for service connection for hypothyroidism. Therefore, as new and material evidence has not been received, his application to reopen such claim must be denied. 2. Entitlement to an initial rating in excess of 10 percent prior to November 19, 2010, in excess of 30 percent from November 19, 2010, to June 19, 2012, and in excess of 50 percent thereafter for anxiety disorder with primary insomnia and depressive disorder. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts founda practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The Veteran's service-connected anxiety disorder with primary insomnia and depressive disorder is evaluated as 10 percent disabling as of March 1, 2010, 30 percent disabling as of November 19, 2010, and 50 percent disabling as of June 19, 2012, under the criteria of Diagnostic Code 9413, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders (General Rating Formula). 38 C.F.R. § 4.130. The General Rating Formula provides a 10 percent rating when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity, due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. The United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas"i.e., "the regulation...requires an ultimate factual conclusion as to the Veteran's level of impairment in most areas." Vazquez-Claudio, 713 F.3d at 117118; 38 C.F.R. § 4.130. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126 (a). The Board notes that the revised DSM-5, which, among other things, eliminates Global Assessment of Functioning (GAF) scores, applies to appeals certified to the Board after August 4, 2014, as is the case here. See 79 Fed. Reg. 45, 093 (Aug, 4, 2014). Consequently, the Board will not consider the previously assigned GAF scores in determining the outcome of this case. See Golden v. Shulkin, 29 Vet. App. 221 (2018). In an October 2011 statement, the Veteran reported that he had experienced significant anxiety since the time of his deployments with the military, and indicated that his anxiety, insomnia, and depression interfered with his sleep and significantly impacted his occupational and social functioning. At the March 2020 Board hearing, the Veteran testified that his psychiatric symptoms had been consistent since the time of his retirement from the military and, thus, he alleges that a 50 percent rating for his psychiatric disability should be assigned as of March 1, 2010, the date of service connection. Turning to the evidence of record, a May 2010 VA examination revealed symptoms of depressed mood, anxiety, occasional panic attacks, and chronic sleep impairment. The Veteran reported a fear of receiving late-night phone calls and anxiety in situations where he feels out of control. Mental status examination was negative for a flattened affect or abnormal speech patterns, panic attacks with weekly frequency, unusual mannerisms or ticks, lack of eye contact, evidence of concentration or memory disturbances, or evidence of poor judgment. Rather, the Veteran's affect was euthymic, he described his mood as being generally good, and reported no suicidal or homicidal ideation. It was also noted that he had a good relationship with his spouse of 30 years, other family members, and friends. In this regard, the Veteran reported no significant problems in making or keeping friends. He also had a successful 33 year military career where he worked as a pharmacist. Upon review, the examiner found that he did not have any clinical dysfunction and, while he had some anxiety, such did not lead to clinically significant problems in terms of his day to day functioning. While the Veteran contends that the May 2010 examiner should have assessed his anxiety with a formal questionnaire as was done during a June 2012 examination, the Board finds that the May 2010 examiner is a competent medical professional as he is a psychiatrist who considered the totality of the evidence and applicable medical principles in providing an assessment of the Veteran's level of occupational and social impairment. Monzingo v. Shinseki, 26 Vet. App. 97, 105-7 (2012); Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). Accordingly, while the examination was not what the Veteran may have expected, the Board finds that it is adequate to rate his psychiatric disability. Furthermore, VA treatment records from November 2010 reflect the Veteran's continued reports of anxiety, worries, and insomnia, and anger and depression related to a deployment two years previously. He further reported that he lived with his spouse and other family members, and was employed. Mental status examination was normal with the exception of an anxious mood, and an affect reflecting anger and depression over his last deployment and worry over his children and finances. In January 2011, the Veteran reported that his insomnia had improved. As noted previously, in an October 2011 statement, the Veteran indicated that he had experienced significant anxiety since the time of his deployments, which he claims significantly interfered with his life. He further reported that his anxiety disorder and other mental health problems continued to interfere with his sleep and impact his occupational and social functioning. However, the Veteran did not provide any specific descriptions that suggested more severe symptomatology resulting in a greater degree of occupational and social impairment than previously recorded during his May 2010 VA examination and subsequent VA treatment records. At a June 2012 VA examination, the Veteran reported symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of mood and motivation, and neglect of personal appearance and hygiene. The examiner also noted that the Beck Anxiety Inventory indicated moderate to severe anxiety that causes impairment in clinical, social, and vocational functioning. Ultimately, he found that the Veteran's psychiatric disability resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation. Subsequent treatment records reflect similar complaints, to include anxiety and insomnia/sleep impairment with difficulty concentrating, with a denial of panic attacks, and normal mental status examinations, with the exception of an anxious and dysthymic mood, through December 2018. Further, at the March 2020 Board hearing, the Veteran testified that he was "fine with the final 50 [percent rating,]" which he believed was accurate, but argued that such rating was warranted for the earlier periods on appeal as he had experienced similar symptomatology since March 2010. Upon review, the Board finds that, for the appeal period prior to June 19, 2012, an initial 30 percent rating, but no higher, is warranted for the Veteran's psychiatric disability. In this regard, the record shows that such disability was manifested by depressed mood, anxiety, occasional panic attacks, and chronic sleep impairment, which result in, at most, occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), which is consistent with a 30 percent rating under the General Rating Formula. In this regard, despite such symptoms, the Veteran demonstrated the ability to establish and maintain effective work and social relationships without difficulty. Specifically, throughout such period, he had a good relationship with his spouse of over 30 years, other family members, and friends. Additionally, at his May 2010 VA examination, he reported that he had no significant problems in making or keeping friends. Moreover, he has successfully maintained employment without any demonstrated deficits in reliability or productivity. Finally, in consideration of the totality of the Veteran's symptoms, the May 2010 VA examiner found that his psychiatric disability any clinical dysfunction and, while he had some anxiety, such did not lead to clinically significant problems in terms of his day to day functioning. Consequently, the Board finds that the Veteran's psychiatric disability does not result in symptomatology of a nature, frequency, severity, or duration so as to result in occupational and social impairment with reduced reliability and productivity prior to June 19, 2012. Furthermore, as of June 19, 2012, the Board finds that the Veteran's psychiatric disability has been manifested by depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of mood and motivation, and neglect of personal appearance and hygiene, resulting in occupational and social impairment with reduced reliability and productivity, which reflects an increase in the nature and severity of his symptomatology as of such date. However, a rating in excess of 50 percent is not warranted as of such date. In this regard, the totality of the Veteran's symptomatology, with the exception of neglect of personal appearance and hygiene, are contemplated by such assigned rating. Further, while a neglect of personal appearance and hygiene is indicative of a 70 percent rating under the General Rating Formula, the Board finds that the nature, frequency, severity, and duration of such symptomatology does not more nearly approximate occupational and social impairment with deficiencies in most areas. In this regard, the record shows that the Veteran continued to establish and maintain effective work and social relationships, and maintained employment without interference. Furthermore, even in consideration of the totality of the Veteran's psychiatric symptomatology, to include neglect of personal appearance and hygiene, the June 2012 VA examiner found that such disability resulted in, at most, occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation, which is consistent with a 30 percent rating under the General Rating Formula. Thus, the evidence does not show, and the Veteran does not contend, that a rating in excess of 50 percent is warranted for his psychiatric disability as of June 19, 2012. The Board has also considered whether additional staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected anxiety disorder with primary insomnia and depressive disorder; however, the Board finds that the Veteran's symptomatology has been stable throughout each period on appeal. Thus, assigning additional staged ratings for such disability is not warranted. Furthermore, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, in regard to the initial rating claim adjudicated herein. 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 decision, the Board has applied the benefit of the doubt doctrine, which has resulted in the award of a 30 percent rating for the Veteran's anxiety disorder with primary insomnia and depressive disorder for the appeal period prior to June 19, 2012. However, as the preponderance of the evidence is against an initial rating in excess of 30 percent prior to such date and in excess of 50 percent thereafter for such disability, that doctrine is not applicable in such regard and his initial rating claim must otherwise be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 3. Entitlement to service connection for an allergy to diphenylguanidine. In a May 2011 statement, the Veteran contended that he had a severe skin rash in response to wearing rubber gloves during service. He explained that, when he was required to wear rubber gloves for the duration of his work day, he developed severe eczema on his hands. He further reported that, when he was allowed reassignment to an area where he did not wear rubber gloves, he saw a dramatic improvement in his symptoms. In his March 2020 Board hearing, the Veteran further explained that, while he did not have residuals of an in-service allergic reaction, he had tested positive for an allergy to diphenylguanidine during service and believed that service connection for such allergy should be awarded. In this regard, in an April 2014 treatment record, the Veteran reported that he experienced eczema in childhood, usually along the areas where bands of clothing rubbed his skin. Additionally, his STRs reflect his report to an allergy to latex in the form of delayed hypersensitivity dermatitis in May 1998. At an April 2010 VA examination, he clarified that he was not actually allergic to latex, rather, it was the accelerator in the rubber of the gloves, i.e., diphenylguanidine. He further indicated that, as he currently had a desk job, he had not been using gloves and did not currently have eczema. The examiner noted that the Veteran had an allergy to rubber gloves as such resulted in a delayed hypersensitivity reaction; however, he was currently symptom-free as he avoided rubber gloves and, thus, such condition had resolved. In June 2014, he tested positive in a rubber panel patch test for allergy to diphenylguanidine. Thus, as the evidence suggests that the Veteran's allergy to diphenylguanidine pre-existed service as evidenced by his report that he developed eczema near the elastic bands of his clothing during childhood, a remand is necessary in order to obtain an addendum opinion so as to determine the nature of such disorder, to include whether it is a congenital defect or disease, and whether such is related to service, to include by way of aggravation. The matter is REMANDED for the following action: Forward the record, to include a copy of this remand, to an appropriate VA examiner so as to obtain an addendum opinion addressing the nature and etiology of the Veteran's allergy to diphenylguanidine. Following a review of the record, the examiner should address the following inquiries: Does the Veteran's allergy to diphenylguanidine constitute a congenital or developmental defect or a disease (per VAOPGCPREC 82-90, in general, a congenital abnormality that is subject to improvement or deterioration is considered a disease)? (i) If the Veteran's allergy to diphenylguanidine is considered a defect, was there additional disability due to disease or injury superimposed upon such defect during service? If so, please identify the additional disability. (ii) If the Veteran's diagnosed allergy to diphenylguanidine is a disease, did such clearly and unmistakably pre-exist his entry to service? (a) If there is clear and unmistakable evidence that the Veteran's allergy to diphenylguanidine pre-existed service, is there clear and unmistakable evidence that the pre-existing disorder(s) did not undergo an increase in the underlying pathology during service, i.e., was not aggravated during service? If there was an increase in the severity of the Veteran's allergy to diphenylguanidine, was such increase clearly and unmistakably due to the natural progress of the disease? (b) If there is no clear and unmistakable evidence that the Veteran's allergy to diphenylguanidine pre-existed service, then is such at least as likely as not (i.e., a 50 percent or greater probability) that the disorder is directly related to service? In offering such opinions, the examiner should consider the Veteran's April 2014 report that experienced eczema in childhood, usually along the areas where bands of clothing rubbed his skin; the May 1998 STR reflecting an allergy to latex in the form of delayed hypersensitivity dermatitis; and the June 2014 positive rubber panel patch test for allergy to diphenylguanidine. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Breckenridge, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.