Citation Nr: 21027822 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 17-58 217 DATE: May 6, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, mood disorder, anxiety, and alcohol use disorder, is denied. Entitlement to service connection for peripheral neuropathy is dismissed. New and material evidence having been received, the petition to reopen the claim of service connection for a lumbar spine disability is granted. The reduction to a noncompensable rating being improper, restoration of the 50 percent rating for service-connected chronic headaches is granted, effective April 9, 2018. REMANDED Entitlement to service connection for urinary bladder cancer is remanded. Entitlement to service connection for a lumbar spine disability is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has an acquired psychiatric disorder that began during active duty service, or is otherwise related to an in-service event, injury, or disease. 2. On the record at the February 2021 videoconference hearing and prior to the promulgation of a decision in the appeal, the Veteran indicated that he wished to withdraw his appeal as to the claim of service connection for peripheral neuropathy. 3. In an August 1992 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for a back disability. The Veteran did not file a notice of disagreement (NOD) and no new and material evidence was received within the appeal period. The evidence received since the August 1992 rating decision is not duplicative or cumulative of evidence previously of record and it raises a reasonable possibility of substantiating the Veteran's claim of service connection for a lumbar spine disability. 4. The reduction of the rating assigned for chronic headaches from 50 percent to 0 percent, effective April 9, 2018, was not proper; restoration of the 50 percent rating is warranted. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, mood disorder, anxiety, and alcohol use disorder, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3.304(f). 2. The criteria for withdrawal of a substantive appeal have been met with respect to the issue of service connection for peripheral neuropathy. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 3. The criteria for reopening the claim of service connection for a lumbar spine disability have been met. 38 U.S.C. §§ 7105; 38 C.F.R. §§ 3.156, 20.1103. 4. The criteria for restoration of a 50 percent rating for chronic headaches, effective from April 8, 2018, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 3.344, 4.2, 4.10, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from July 1965 to September 1991. These matters come before the Board of Veterans' Appeals (Board) from rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO) in January 2013, May 2015, and June 2018. In the January 2013 rating decision, the RO denied service connection for peripheral neuropathy and posttraumatic stress disorder (PTSD). It also determined that the Veteran had submitted new and material evidence sufficient to reopen his previously denied service connection claim for a back disability, but ultimately denied service connection. In the May 2015 decision, the RO, in relevant part, denied a claim of service connection for urinary bladder cancer. In the June 2018 rating decision, the RO decreased the rating for the Veteran's service-connected chronic headaches from 50 percent to 0 percent, effective from April 9, 2018. Following certification of the appeal, the RO granted service connection for diabetic peripheral angiopathy of the bilateral lower extremities in a December 2017 rating decision. The grant of service connection constitutes a full award of benefits sought on appeal with respect to the claim of service connection for a chronic disability of the feet, to include peripheral neuropathy. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). The record currently available to the Board contains no indication that the Veteran has initiated an appeal with respect to the initial rating or effective date assigned. Id. (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). Thus, this issue is not in appellate status at this juncture. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a videoconference hearing in February 2021 regarding the issues of service connection for peripheral neuropathy, urinary bladder cancer, lumbar spine disability, and an acquired psychiatric disorder. A copy of the hearing transcript has been reviewed and associated with the claims file. In the Veteran's December 2019 substantive appeal, or Form 9, regarding his service-connected headaches, he indicated that he did not desire a hearing on that issue. The Board acknowledges that the Veteran filed a premature Form 9 in June 2018, indicating that he wanted a hearing. However, given the subsequent Form 9 submitted in December 2019 indicating that the Veteran did not wish to schedule a Board hearing, the Board finds that any hearing request with respect to his chronic headache disability has been waived. Moreover, this issue has been granted in full in this decision. Accordingly, there is no prejudice to the Veteran with proceeding with a decision on the merits. The Board notes that the Veteran filed a claim for depression in September 2016. However, the scope of the Veteran's mental health disability claim includes any mental disability that may be reasonably encompassed by the Veteran's description of the claim, reported symptoms, and other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 4-6 (2009). In the present case, the evidence shows multiple possible mental health diagnoses, including anxiety, mood disorder, PTSD, depression, and alcohol use disorder. 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, mood disorder, anxiety, and alcohol use disorder Service connection will be granted for a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires evidence of (1) a current disability; (2) 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). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for PTSD generally requires: (1) medical evidence diagnosing the condition in accordance with applicable criteria; (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f); Anglin v. West, 11 Vet. App. 361, 367 (1998). A new fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) was released and represents the most up-to-date clinical diagnostic guidelines. This revised version of the DSM applies to all claims pending at the RO on or after August 4, 2014, as was the case here. See 38 C.F.R. § 4.125(a). The Board must fully consider all lay statements of record. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A layperson is competent to report on the onset of disability and, when applicable, continuity of his or her current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (stating that a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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, 1376-77 (Fed. Cir. 2007). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. Except as otherwise provided by law, the Veteran has the responsibility to present and support a claim for benefits. 38 U.S.C. § 5107(a). The Veteran's VA and private treatment records note various mental health disorders, including PTSD, depression, mood disorder, anxiety, and alcohol abuse disorder. He asserts that these disorders were incurred in, or are otherwise related to, his active duty service. The Veteran underwent a VA psychiatric examination in December 2012 in conjunction with his claim for PTSD. The examiner listed the significant loss of loved ones, experiencing mortar fire in Vietnam, witnessing a tornado during childhood, seeing the decapitated body of his cousin after a motor vehicle accident prior to service, and his impending retirement as psychosocial and environmental problems that may contribute to a mental disorder. In particular, the Veteran stated that the experience of the tornado, during which one of his neighbors died, is always in his mind. The examiner provided diagnoses of an anxiety disorder and alcohol abuse in full sustained remission but found that his symptomatology did not meet the DSM-IV criteria for PTSD because he did not have persistent avoidance of stimuli associated with trauma or numbing of general responsiveness. The examiner also stated that he was unable to provide an etiology opinion regarding his anxiety disorder, indicating that doing so would result in mere speculation. Another VA examination was conducted in May 2018, in which the examiner stated that he could not diagnose the Veteran with PTSD or any other psychiatric disorder that conforms to the DSM-V criteria. The examiner suspected that the Veteran was exaggerating or feigning his symptoms, describing his responses as "a structured inventory of malingered symptomatology." He indicated that the Veteran's total score was significantly above the recommended cutoff for identifying suspected malingering and that the Veteran reported a high frequency of symptoms that are highly atypical of patients with genuine psychiatric disorders. The suspected malingering of symptoms, the examiner stated, made it impossible to provide any accurate diagnosis or finding of functional impairment but did not necessarily mean that he does not have a psychiatric disorder. The Board notes that the Veteran scored 70 out of 80 on the PCL-5 assessment for PTSD during a March 2016 VA social work appointment, and that the treating VA social worker stated that, in his opinion, the Veteran has PTSD. However, the social worker gave no indication that he was providing a formal diagnosis under the DSM-V criteria. Further, PCL-5 scores are used to provide provisional diagnoses only, and there is no evidence of a confirmed PTSD diagnosis in accordance with the DSM-V criteria. The Veteran asserts that his psychiatric problems began during service. However, aside from reporting a history of trouble sleeping and nervous trouble related to job stress in March 1984, his service treatment records do not show any complaints of, diagnosis of, or treatment for mental health disorders. During the February 2021 hearing, the Veteran testified that he saw a civilian doctor during service who diagnosed him with a psychiatric disorder of some sort, but he did not seek treatment through VA or the military during service because he feared that it would negatively affect his military career. He also testified he was diagnosed with PTSD by a non-VA physician in 1992 and was re-diagnosed in 2011. The Board acknowledges the various treatment records noting various mental health diagnoses, including PTSD, depression, and mood disorder. However, the Board puts more weight on the May 2018 examiner's opinion because he reviewed the record and examined the Veteran before concluding that he did not have a diagnosis that conforms to the DSM-V. Even if the Veteran were found to have a psychiatric disability diagnosed using the DSM-V criteria, there is no medical opinion of record supporting a nexus between a mental health disorder and his service. While he asserts that his psychiatric disorders are related to service, the Veteran's treatment records point to several other sources. As indicated above, he has stated that he experienced a tornado as a child and saw the decapitated body of his cousin, both of which are stressors for his claimed PTSD. His VA treatment records attribute his claimed disorders to his general medical condition and multiple physical disabilities. The Veteran has stated that concerns over elevated immunoglobulin A levels and his wife's discovery of his extramarital affair led to an April 2013 alcohol abuse relapse, suicide attempt, and DUI. In October 2013 and March 2016, he stated that guilt over the April 2013 incident caused further mental anguish. He also told a VA physician in May 2013 that he was depressed by the fact that he has had to take many medications since retiring, and a September 2016 VA treatment record indicates health issues and life transitions as causes of his claimed disability. The 2012 examiner was unable to provide a nexus opinion regarding his anxiety disorder, and there are no medical opinions of record affirming a connection between any diagnosed psychiatric disorder and his service. The Board finds that the Veteran is competent to testify regarding his symptoms and the progression of his claimed psychiatric disabilities. However, his inconsistent statements; the May 2018 examiner's suspicion that he was malingering or feigning symptoms; and a June 2013 treatment record stating that he was "vague, evasive, [and] elusive" when answering questions about his psychiatric disability, weigh against his credibility for the purpose of adjudicating the matter at hand. In adjudicating this claim, the Board has considered all relevant evidence favorable to the Veteran, including his statements that his psychiatric disorder(s) and alcohol use had their onset during service, as well as evidence of two in-service DUIs. However, evidence of two DUIs during a 26-year term of service is not necessarily indicative of an acquired psychiatric disorder. Further, while the Veteran is competent to testify as to the continuity of symptomatology he has experienced over the years, he is not a mental health professional with the specialized knowledge and experience to diagnose a psychiatric disorder and there are no confirmed mental health diagnoses of record during service or within one year of separation. After considering all the relevant evidence of record, the Board finds that the preponderance of the evidence weighs against a grant of service connection for an acquired psychiatric disorder. The Veteran does not have a current mental health diagnosis under the DSM-V. Further, although the December 2012 examiner indicated that he had an anxiety disorder and alcohol use disorder in remission pursuant to DSM-IV, he stated that he was unable to provide an opinion as to whether these disorders were related to service. Therefore, the requirements for service connection have not been met and the claim must be denied. In denying the claim, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Accordingly, the Board finds that service connection for an acquired psychiatric disorder is not warranted. 2. Entitlement to service connection for peripheral neuropathy The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105(d); 38 C.F.R. § 20.205. At any time before the Board promulgates a decision, an appellant or his or her authorized representative may withdraw a substantive appeal as to any or all issues either on the record at a hearing or in writing. 38 C.F.R. § 20.205. At the February 2021 videoconference hearing, the Veteran indicated that he wished to withdraw his appeal as to the issue of entitlement to service connection for peripheral neuropathy. The Board notes that a verbal withdrawal of an appeal at a hearing is effective "only where it is (1) 'explicit;' (2) 'unambiguous;' and (3) 'done with a full understanding of the consequences of such action on the part of the [veteran].'" See Acree v. O'Rourke, 891 F.3d 1009, 1012-1013 (Fed. Cir. 2018) (quoting DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011)) (explaining that the Board must consider all three prongs of the DeLisio standard when determining whether a verbal withdrawal of a claim is effective). In the present case, the Veteran was fully informed of the consequences of withdrawing his appeal at the hearing, and he explicitly and unambiguously agreed to withdraw the claim of service connection for peripheral neuropathy. The withdrawal was confirmed by the Board prior to the promulgation of a decision on the appeal. As such, there remain no allegations of error of fact or law for appellate consideration as to this issue. Accordingly, this issue is no longer within the Board's jurisdiction and is dismissed. See Hamilton v. Brown, 4 Vet. App. 528 (1993) (en banc), aff'd, 39 F.3d 1574 (Fed. Cir. 1994) (holding that the Board is without authority to proceed on an issue if the claimant indicates that consideration of that issue should cease). 3. Whether new and material evidence has been received to reopen the claim of service connection for a lumbar spine disability Applicable law provides that a final decision cannot be reopened unless new and material evidence is presented. 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decision makers. 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. 38 C.F.R. § 3.156(a). 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. Id. The credibility of the evidence is presumed in determining whether new and material evidence has been submitted. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA's duty to assist or through consideration of an alternative theory of entitlement. Id. At 118. In the present case, the Veteran's claim of service connection for a back disability was denied in an August 1992 rating decision because a December 1991 VA examination indicated a clinically normal musculoskeletal system. The relevant evidence of record at the time of the August 1992 rating decision consisted of the claim form, service treatment records, and the December 1991 VA examination report. The Veteran was notified of this decision in an August 1992 letter. He did not submit a Notice of Disagreement (NOD) or submit new and material evidence within one year of the rating decision. Thus, the August 1992 rating decision became final. Since the August 1992 rating decision, VA and private treatment records, a December 2012 VA examination report, and the February 2021 hearing transcript have been associated with the claims file. After a review of the evidence, the Board finds that new and material evidence has been received to reopen the claim of service connection for a lumbar spine disability. The evidence is new, as it was not part of the record at the time of the August 1992 rating decision. It is also material, as it relates to unestablished facts necessary to substantiate the claim. Specifically, the Veteran has submitted evidence establishing a current diagnosed lumbar spine disability. For example, the 2012 VA examination reveals a diagnosis of degenerative lumbar disease. Accordingly, the evidence is new and material and the claim of service connection for a lumbar spine disability is reopened. 4. Propriety of the reduction of the disability rating assigned for chronic headaches from 50 percent to 0 percent, effective April 9, 2018 Specific legal standards govern whether the reduction in the ratings for the Veteran's chronic headache disability was justified by the evidence. A veteran's disability rating will not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C. § 1155. Where a disability rating has been continued for at least five years at the same level, under 38 C.F.R. § 3.344, if there have occurred changes in essential medical findings or diagnosis, that case is to be reviewed and adjudicated so as to produce the greatest degree of stability of disability evaluation. In determining the propriety of a previous rating, the entire record as to medical history should be considered to ascertain whether the most recent examination is indeed a full and complete depiction of the level of disability. 38 C.F.R. § 3.344(a). Likewise, in such cases, provided doubt remains, after according due consideration to all the evidence developed by the several items discussed in the preceding paragraph (section 3.344(a)), the rating agency will continue the rating in effect under specified procedures. 38 C.F.R. § 3.344(b). In the present case, the 50 percent rating assigned for the Veteran's service-connected chronic headache disability was in effect from September 10, 2015 to April 8, 2018, which is less than five years. Therefore, the provisions of 38 C.F.R. § 3.344(a) and (b), which govern the reduction of protected rating in effect for five years or more, do not apply in this case. Accordingly, reexaminations reflecting improvement in the Veteran's chronic headache disability will warrant reduction in rating. 38 C.F.R. § 3.344(c). The determination in a reduction rating case must include the proper application as to the standard of proof. In rating reduction cases, VA must establish, by a preponderance of evidence, that the reduction was warranted. Brown v. Brown, 5 Vet. App. 413, 421 (1993); Kitchens v. Brown, 7 Vet. App. 320, 324 (1995). A reduction in rating must be based upon review of the entire history of the disability. Brown, 5 Vet. App. at 420; see also 38 C.F.R. §§ 4.1, 4.2, 4.10. VA must then ascertain whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based on thorough and adequate examinations. Faust v. West, 13 Vet. App. 342, 349 (2000). Finally, it must be determined whether the improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. Brown, 5 Vet. App. at 421. There must be an actual improvement in the disability and not just a failure to meet the requirements of a rating under the currently assigned diagnostic code. In sum, in any rating-reduction case, VA must determine (1) whether the evidence reflects an actual change in the disability based upon review of the entire recorded history of the condition; (2) whether the examination reports reflecting such change are based upon thorough examinations; and (3) whether any improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. Murphy v. Shinseki, 26 Vet. App. 510, 516-17 (2014) (citing Brown, 5 Vet. App. at 421; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.13) When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When a rating reduction is considered and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction must be prepared and mailed to the Veteran's address of record. 38 C.F.R. § 3.105(e). This proposed rating should set forth all the material facts and reasons for the proposed reduction. Id. The Veteran must be given 60 days to present additional evidence showing that compensation payments should be continued at the present level. Id. In the present case, the RO reduced the rating for the Veteran's chronic headaches from 50 percent to 0 percent in a June 2018 rating decision, without issuing a proposed rating reduction or allowing the Veteran to submit additional evidence. However, this evaluation did not reduce or discontinue the compensation payments being made to the Veteran, as the reduced rating did not affect his combined disability evaluation of 90 percent. Thus, the procedural requirements of 38 C.F.R. § 3.105(e) do not apply. The RO assigned a 50 percent rating for the Veteran's chronic headaches in a February 2016 rating decision, based on a February 2016 VA medical opinion. At that time, the examiner indicated that the Veteran experienced pulsating or throbbing pain localized to one side of the head, and that physical activity worsened his symptoms. The examiner also noted that his headaches caused symptoms of nausea and sensitivity to light and sound. The Veteran's headaches typically lasted for less than one day. The examiner also indicated that he experienced characteristic prostrating attacks of migraine headache pain very frequently, more than once a month. Another VA examination was conducted in November 2016, in which the examiner indicated that the Veteran experienced pulsating or throbbing head pain that worsened with physical activity and caused nausea and light sensitivity. His headaches typically lasted less than one day, and the examiner indicated that he experienced characteristic prostrating attacks. The Veteran indicated that he got bad headaches about once a week that required him to stop working and go to a quiet place until his symptoms improved, and the examiner opined that this impacted his ability to work. In the April 2018 examination, the Veteran reported symptoms of a sharp pain localized on one side of the head and nausea. He also reported sensitivity to light and sound, but indicated that these sensitivities are always present, regardless of whether he has a headache. He stated that his headaches typically last for 45 minutes to one hour, and he goes into a dark and quiet room until they improve. The examiner indicated that he did not experience characteristic prostrating attacks and that his disability did not impact his ability to work. Based on the April 2018 examination findings, in a June 2018 rating decision, the RO reduced the disability rating for the Veteran's chronic headaches from 50 percent to noncompensable, effective April 9, 2018. Based on a review of the evidence, the Board finds that the April 2018 examination did not show any improvement in the Veteran's chronic headaches. Although the examiner indicated that he did not experience prostrating attacks, her notes do not show any real improvement in the Veteran's ability to function under the ordinary circumstances of life and work. Further, her examination notes show that he would have to go to a quiet and dark room until his headaches passed, but she concluded that this did not impact his ability to work. The November 2016 examiner also noted this and came to the opposite conclusion. The evidence indicates that the Veteran experienced similar symptoms during the February 2016, November 2016, and April 2018 VA examinations, with no evidence of tangible improvement shown. Additionally, newer evidence suggests that the Veteran's headaches have not improved. For instance, he indicated in a June 2019 VA examination that he experienced twelve to eighteen headaches per month, with an average duration of three hours. He reported in a January 2020 examination that his headaches typically last three or four hours but can last for days. His private treatment records show that he was treated twice with occipital nerve blocks in June and August 2019 after reporting migraines lasting four days each, and he received a supraorbital nerve block in December 2019 after reporting pain behind the eyes associated with light and sound sensitivity. Accordingly, there is no evidence of an actual improvement in the Veteran's chronic headache disability under the ordinary conditions of life and work. Importantly, while the more recent evidence adds context, the Board's conclusion in this case can be reached based solely on the evidence of record at the time the reduction was made. As noted above, VA must establish, by a preponderance of the evidence, that the reduction was warranted in accordance with 38 C.F.R. § 3.344. Brown, 5 Vet. App. at 421. The Board finds that this burden has not been carried by VA given that the findings in the February and November 2016 versus April 2018 VA examinations do not reflect an improvement in the Veteran's ability to function under the ordinary conditions of life and work. Accordingly, restoration of the 50 percent disability rating for his service-connected chronic headaches, effective April 9, 2018, is warranted. 38 U.S.C. § 1155; 38 C.F.R. § 3.105. REASONS FOR REMAND 1. Entitlement to service connection for urinary bladder cancer is remanded. VA is obligated to provide an examination or obtain a medical opinion in a claim of service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. McLendon, 20 Vet. App. at 83. The Veteran's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. Id. at 83. As detailed below, the Board finds that the Veteran is entitled to a VA examination to determine the nature and etiology of his urinary bladder cancer. The Veteran had service in Vietnam during the period between January 9, 1962 and May 7, 1975. Thus, exposure to certain herbicide agents (Agent Orange) is conceded. 38 C.F.R. § 3.307(a)(6). The Veteran's private treatment records and hearing testimony indicate that he was diagnosed with urinary bladder cancer, which was subsequently removed. The Veteran testified that his cancer is currently in remission and requires twice-yearly screening. He has asserted that his cancer is related to his service, to include as secondary to exposure to herbicide agents in Vietnam. The Veteran's VA and private treatment records indicate that he received treatment for a bladder tumor by Dr. M.C., M.D.. Dr. C. performed a cystourethroscopy and bladder biopsy in December 2009, which resulted in diagnoses of hematuria, bladder lesion, and cystitis cystica. Subsequent treatment records from Dr. C.'s practice reflect continued surveillance of the Veteran's bladder, alternately referring to bladder cancer and a bladder tumor. However, the evidence in the claims file does not indicate an exact diagnosis date. Based on the Veteran's treatment records indicating a bladder cancer diagnosis and his February 2021 hearing testimony that he continues to see Dr. C. to monitor it, the Board finds that the Veteran has presented competent evidence that he has a current disability or signs or symptoms of a current disability. He asserts that his bladder cancer is related to his service, to include as due to exposure to herbicide agents while in Vietnam. Thus, the Board finds that a VA examination is necessary to determine the nature and etiology of his claimed disability. 2. Entitlement to service connection for a lumbar spine disability is remanded. Throughout the rating period on appeal, the Veteran has been diagnosed with degenerative disc disease of the lumbar spine and asserts that it was incurred in service. His service treatment records reveal complaints of back pain in May and June 1989, February 1990, and April 1991. An MRI was taken of the Veteran's lumbar spine in March 2010, which revealed severe facet osteoarthritis at L4-L5 with spinal stenosis, foraminal narrowing, and encroachment of the exiting L4 nerve roots, and evidence of lumbar radiculopathy was noted on the L4 and L5 vertebrae. An additional MRI in December 2011 showed advanced degenerative disc change with disc desiccation and disc space narrowing at L4-L5 and L5-S1, as well as mild spondylolisthesis of L4 on L5 with associated degenerative facet arthropathy. These changes resulted in prominent spinal canal stenosis and lateral recess stenosis at L4-L5 with bilateral nerve root impingements. A VA examination of the Veteran's lumbar spine was conducted in December 2012. The examiner gave diagnoses of degenerative lumbar disc disease and lumbar strain and opined that neither diagnosis was related to his service. The examiner noted the Veteran's documented in-service lumbar strain but stated that strains, by definition, resolve without residuals. Because the Veteran had no other complaints of lumbar pain after separation until he injured his back while lifting a heavy object in 2009, and his degenerative disc disease was diagnosed nineteen years after discharge, the examiner opined that his back disability is less likely than not related to service. In support of his opinion, the examiner referred to an in-service diagnosis of back strain, stating that strains resolve without residuals. However, a June 1989 treatment note refers to his back injury as a sprain, rather than a strain. The examiner's opinion does not discuss the possibility that the Veteran's in-service injury was a sprain or whether a sprain could cause the Veteran's current claimed lumbar spine disabilities. Additionally, the examiner pointed out that the Veteran did not have any complaints of lumbar pain from his separation from service in 1991 until 2009. However, the Veteran has indicated several times that his back pain has been persistent since service. In an April 1991 report of medical history, he endorsed a history of recurrent back pain and arthritis, rheumatism, or bursitis. He also indicated in a VA treatment note dated in September 2012 that his lower back pain began in the military and has been present for years. The Board finds that the December 2012 lumbar spine VA examination is inadequate for the purposes of adjudicating this claim because the examiner did not discuss the in-service notation of a back sprain; his claimed medical history of recurrent back pain and arthritis, rheumatism, or bursitis; or statements that his symptoms have been present since his separation from service. Therefore, a new examination is warranted. The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file the Veteran's updated VA treatment records, from January 2020 to the present, including any updated mental health records. 2. After completion of #1, schedule the Veteran for a VA examination to determine the nature and etiology of his bladder cancer. The claims folder, including a copy of this remand, must be made available to the examiner and such review should be noted in the examination report. Based on a review of the Veteran's pertinent history and the examination results, the examiner(s) should identify any tumor(s) and/or cancer(s) of the bladder. For any tumor or cancer identified, the examiner should indicate the date of its onset. For any cancer(s) and/or tumor(s) identified, the examiner should opine as to whether it is at least as likely as not (a probability of at least 50 percent) that it is caused by, or is otherwise related to, his service, to include as due to exposure to herbicide agents in Vietnam. The examiner is advised that the Veteran's exposure to Agent Orange is conceded. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. The examiner must provide a comprehensive rationale for each proffered opinion. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. As appropriate, the AOJ should conduct additional development or supplement the record. 3. After completion of #1, schedule the Veteran for a VA examination to determine the nature and etiology of his claimed lumbar spine disability. The claims folder, including a copy of this remand, must be made available to the examiner and such review should be noted in the examination report. The examiner should opine as to the following: (a.) Is it at least as likely as not (a probability of at least 50 percent) that the Veteran's lumbar spine disability was incurred in service or is otherwise related to an in-service event, injury, or illness, to include a back sprain? (b.) Is it at least as likely as not (a probability of at least 50 percent) that the Veteran's osteoarthritis manifested to a compensable degree within one year of separation from service? The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. The examiner must provide a comprehensive rationale for each proffered opinion. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. As appropriate, the AOJ should conduct additional development or supplement the record. 4. After completion of #1 through #3, readjudicate the issues on appeal, to include consideration of the additional VA examination reports and treatment records since the last Statement of the Case (SOC) in October 2017. If the benefits sought on appeal are not granted in full, issue the Veteran and his representative a Supplemental Statement of the Case (SSOC) and provide the Veteran an opportunity to respond. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Pratt 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.