Citation Nr: 21028449 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 17-55 915A DATE: May 11, 2021 ORDER The petition to reopen the claim for entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for an acquired psychiatric disability and/or PTSD due to military sexual trauma (MST) is granted. Entitlement to a 30 percent rating for the Veteran's service-connected hypothyroidism is granted. REMANDED Entitlement to a rating in excess of 10 percent for the Veteran's service-connected lumbar spine disability is remanded. Entitlement to a compensable rating for pilonidal cyst is remanded. FINDINGS OF FACT 1. The Veteran's claim of entitlement to service connection for PTSD was denied in a July 2009 rating decision. The Veteran did not timely appeal the claim or submit additional evidence. Thus, the July 2009 rating decision became final. 2. New and material evidence has been received since the July 2009 rating decision, which, links the Veteran's current acquired psychiatric disability to active service. 3. The Veteran's acquired psychiatric disability has been linked to her active service by a medical professional. 4. The Veteran's hypothyroidism symptoms have been manifested by fatigability, constipation, and mental sluggishness; however, her hypothyroidism did not manifest in cold intolerance, muscular weakness, mental disturbance, cardiovascular involvement, bradycardia (less than 60 beats per minute), and/or myxedema. CONCLUSIONS OF LAW 1. New and material evidence has been received; this claim of entitlement to service connection for an acquired psychiatric disability and/or PTSD consequently is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. §§ 3.104(a), 3.156, 3.160(d), 20.200, 20.1103 (2020). 2. The criteria for service connection for an acquired psychiatric disability and/or PTSD has been met. 38 U.S.C. § 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2020). 3. The criteria for a 30 percent rating, but no greater, for hypothyroidism have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.21, 4.119, Diagnostic Code (DC) 7903(2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1998 to February 2006. In January 2021, the Veteran testified at a video conference hearing (hearing) before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. Although the Veteran disagreed with the decision denying service connection for sinusitis, in October 2017 the Regional Office (RO) granted service connection for sinusitis. See October 2017 Rating Decision. Thus, the service connection claim for sinusitis is no longer before the Board of Veterans' Appeals (Board) because a grant of service connection constitutes a full grant of benefits on appeal. Grantham v. Brown, 111 F.3d 1156 (Fed. Cir. 1997). The Board notes that the Veteran originally filed a claim for PTSD. However, the evidence of record confirms that she has other acquired psychiatric disabilities including adjustment disorder with mixed anxiety and depressed mood and major depressive disorder. See Clemmons v. Shinseki, 23 Vet. App. 1, 6 (2009) (VA has an obligation to consider whether possible mental disorders are service connected if those disorders are indicated by the evidence in the record even if the Veteran's claim does not specifically identify those disorders). Thus, the Veteran's claim has been recharacterized more broadly to reflect the different diagnoses. The Veteran's initial claim for PTSD was denied in 2009 and became a final decision. Although the claim has been reopened as suggested by the April 2012 VA examination report, the Board must address whether new and material evidence has been submitted to reopen this claim. This matter goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim on a de novo basis. See Barnett v. Brown, 83 F. 3d 1380, 1383 (Fed. Cir. 1996). Consequently, the issue has been captioned above as a petition to reopen the claim. 1. The petition to reopen the claim for PTSD The Board must determine whether new and material evidence has been received to reopen the Veteran's claim for entitlement to service connection for an acquired psychiatric disability. Generally, a claim that has been denied in a final unappealed decision may not thereafter be reopened and allowed. An 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, VA shall reopen the claim and review the former disposition of the claim. New and material evidence is defined as evidence not previously submitted to agency decision makers that bears directly and substantially upon the specific matter under consideration; such new and material evidence can neither be cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 U.S.C. § 3.156(a); Hickson v. Shinseki, 23 Vet. App. 394, 398 (2010). The Board will generally presume the credibility of the newly submitted evidence for determining whether new and material evidence has been presented. Duran v. Brown, 7 Vet. App. 216, 220 (1994). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In deciding whether new and material evidence has been submitted, the Board looks at the evidence submitted since the last final denial of the claim on any basis. Hickson v. West, 12 Vet. App. 247, 251 (1999). The application to reopen the claim for entitlement to service connection for an acquired psychiatric disability is granted. The Veteran's claim for PTSD was initially denied in a June 2009 Rating Decision. Following the decision, the Veteran submitted additional evidence. Thus, in a July 2009 Rating Decision, the RO reconsidered the claim and denied service connection for an acquired psychiatric disability and PTSD. The RO denied the claim for PTSD for lack of corroboration of an in-service stressor. See July 2009 Rating Decision. The claim for adjustment disorder was denied because it was not related to her service-connected thyroidectomy. Id. The Veteran was notified of the July 2009 Rating Decision but did not appeal the decision, thus it became final a final decision. See 38 U.S.C. §§ 7105, 38 C.F.R. § 20.1103. At the time of the July 2009 Rating Decision, the evidence of record included the Veteran's service treatment records (STRs), November 2008 VA Form 21-4138, May 2009 VA PSTD Stressor Memorandum, St. Louise VA Medical Center treatment records from October 2008 to April 2009, and VA examination reports dated January 2009 and May 2009. The evidence since the July 2009 Rating decision includes a March 2012 VA examination report, lay statement dated February 2012 explaining the MST, a September 2014 VA Form 21-0781 Statement in Support of Claim for PTSD, lay statements from fellow soldiers dated February 2021, excerpt of Associated Press article from March 2003, and hearing testimony from January 2021, a private medical opinion from Dr. S.S. dated March 2020. The Board finds that the evidence is new as it was not previously before the agency and it is relevant because it relates to the issues of her in-service stressor and MST occurrence as well as a nexus between current disability and active service. Notably, the lay statements supported the Veteran's assertions of stressors while serving in Iraq which included being involved in mortar attacks. Additionally, Dr. S.S. provided a medical opinion linking the Veteran's acquired psychiatric disability to her active service. Accordingly, the Veteran's claim for an acquired psychiatric disability is reopened based on new and material evidence. 2. Service Connection The Veteran contends that her acquired psychiatric disability and/or PTSD was caused by her in-service experiences while serving in Iraq and due to experiencing MST during service. See February 2012 Statement from Veteran; September 2014 VA Form 21-0781 Statement in Support of Claim for PTSD. Legal Criteria Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained in the line of duty during active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303 (d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Relevant Facts and Analysis The Veteran was diagnosed with adjustment disorder during the May 2009 VA examination. See May 2009 VA Mental Disorders Examination. She was also diagnosed with major depressive disorder rule out PTSD by a VA psychiatrist. See August 2017 VA Mental Health Medication Management Note in CAPRI received August 2017. Thus, the first element of service connection has been established. The Veteran has provided several lay statements including testimony during the January 2021 Board hearing of traumatic experiences during active service. She testified that while serving in Iraq, she was in her tent on the flight line when a mortar attack occurred which injured one of the soldiers she supervised, and that she had problems with radio equipment and was unable to communicate with Command. See Hearing Transcript. She also described witnessing a fellow soldier attacking fellow soldiers while she was in line at the PX and that he used "a U.S. military vehicle and was driving and running people over who were standing in line." Id. The Veteran submitted buddy statements from Mr. K.C., Ms. D.T.-C., and Ms. C.S.B.., who corroborated the Veteran's account of the traumatic experiences while serving in Iraq. Finally, she submitted an excerpt of a March 2003 Associated Press article entitled "Army: U.S. Soldier Acted Out of Resentment in Grenade Attack." The Board also notes that the Veteran provided a lay statement dated February 2012 explaining the MST she experienced The Board finds that the Veteran is competent to report the traumatic events she experienced or witnessed. Importantly, the Veteran's statements are credible because her statements regarding her experiences were consistent with the evidence of record and corroborated by buddy statements and an article. As such, the second element of service connection, an in-service event or occurrence, has been met. The question before the Board is whether the Veteran's current disability is related to active service. The record contains two positive nexus opinions. The May 2009 VA examiner provided a positive nexus opinion for the Veteran's adjustment disorder. See May 2009 Mental Disorders Examination. Specifically, she stated that the Veteran's "Adjustment Disorder is more likely than not a result of the veteran's stressful military experiences (including both combat and MST)." Id. In a private medical opinion dated March 2020, Dr. S.S. opined that the Veteran's PTSD is more likely than not due to the in-service stressors she experienced. See March 2020 Private Review PTSD Disability Benefits Questionnaire (DBQ). Notably, Dr. S.S. considered the Veteran's MST experience and stressor involving the U.S. soldier who attacked fellow soldiers. The Board finds the May 2009 VA medical opinion and the March 2020 private opinion from Dr. S.S. are based on the Veteran including consideration of the Veteran's statements of symptoms she experienced during active service. Additionally, these opinions are based on knowledge of the Veteran's treatment history and is consistent with the evidence of record. Therefore, the Board accords great probative value to the May 2009 VA medical opinion and March 2020 private medical opinion. Based on the above and resolving all reasonable doubt in favor of the Veteran, the Board finds that the weight of the evidence supports a grant of service connection. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Accordingly, service connection for an acquired psychiatric disability including adjustment disorder, major depressive disorder is granted. 3. Hypothyroidism The Veteran seeks a rating in excess of 10 percent for her service-connected thyroidectomy (thyroid condition). See October 2010 VA Form 21-4138, Statement in Support of Claim. Legal Criteria The Veteran has been assigned a 10 percent disability rating for her hypothyroidism since February 2007 under 38 C.F.R. § 4.119, DC 7903. The criteria were amended effective December 10, 2017. See 82 Fed. Reg. 50802 (November 2, 2017). Under that prior version, a 10 percent evaluation is assigned where there is fatigability or the required use of continuous medication for control of symptoms. A 30 percent evaluation is warranted for fatigability, constipation, and mental sluggishness. A 60 percent evaluation is warranted for muscular weakness, mental disturbance, and weight gain. The maximum, 100 percent disability rating, is warranted for hypothyroidism with cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. Id. The current version of the criteria, effective December 10, 2017, provide that a 100 percent rating is assigned for hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)), but only for a period of six months after an examiner has determined that the condition has stabilized. Thereafter, the residual effects of hypothyroidism are to be rated under the appropriate diagnostic code(s) within the appropriate body system(s) (e.g., eye, digestive, and mental disorders). 38 C.F.R. § 4.119, DC 7903. Also, under the current criteria, hypothyroidism without myxedema warrants a 30 percent rating for six months after initial diagnosis. Thereafter, residuals of the disease, to include eye conditions, or medical treatment, are rated under the most appropriate diagnostic code(s) under the appropriate body system (e.g., eye, digestive, mental disorders). 38 C.F.R. § 4.119, DC 7903. Where the rating criteria are amended during an appeal, the Board considers both the former and the current schedular criteria and, should an increased rating be warranted under revised criteria, that award may not be made effective before the effective date of the change. The rating criteria for Diagnostic Code 7903 are not conjunctive, cumulative, or successive. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Accordingly, "a veteran could potentially establish all of the criteria required for either a 30% or 60% disability rating, without establishing any of the criteria for a lesser disability rating." Id. (emphasis omitted). Factual Background The Veteran filed a claim for increase for her service-connected thyroid condition in October 2010. See October 2010 VA Form 21-4138, Statement in Support of Claim. Therefore, the relevant temporal focus is one year prior to the date of receipt of the claim, accordingly the appeal period began on October 25, 2009. 38 C.F.R. § 3.400. The Veteran's VA treatment records from November and December 2009 indicate the Veteran was prescribed Levothyroxine and needed to undergo laboratory for her thyroid condition. See November 2009 VA Primary Care Women's Health Note and December 2009 Addendum in CAPRI received August 2010. In a statement dated December 2010, the Veteran indicated she experienced symptoms of hot flashes, inability to gain or maintain weight, excessive thirst, mood swings, and constant fatigue. See December 2010 VA Form 21-4138. The Veteran was provided a VA examination in connection with her claim in December 2010. See December 2010 VA Thyroid and Parathyroid Disease Examination. The Veteran endorsed symptoms of tiredness, cold or heat intolerance, weight loss or gain, and gastrointestinal symptoms. Id. She also reported that she experienced mood swings, exhaustion, insomnia as well as hot flashes. The Veteran had a scar on her low-neck area associated with the thyroidectomy, which was not painful or unstable. In March 2011, the Veteran was referred to a VA endocrinologist for complaints of hot flashes and night sweats. See March 2011 VA Endocrinology Note in CAPRI received November 2011. She reported constant fatigue and constipation but noted her weight was stable. Id. The Veteran was provided another VA examination for her thyroid condition in April 2012. See April 2012 Thyroid and Parathyroid Conditions DBQ. The examiner confirmed the Veteran's hypothyroidism diagnosis. The Veteran endorsed symptoms of night sweats, fatigue, severe thirst, and increased urination. The examiner confirmed the Veteran's thyroid condition required continuous medication. She found that the Veteran's thyroid condition was associated with fatigability. Id. In October 2013, the Veteran denied any weight change, fever, or chills. See October 2013 VA Dermatology Note in CAPRI received March 2014. VA treatment records from November 2013 confirm she was prescribed polyethylene glycol for constipation. See November 2013 Primary Care Women's Health Note in CAPRI received April 2014. The Veteran also underwent a VA examination for her thyroid condition in December 2014. See December 2014 VA Thyroid and Parathyroid Conditions DBQ. The Veteran endorsed the following symptoms: fatigability, constipation, mental sluggishness, depression, sleepiness, cold intolerance, and night sweats. The examiner noted her thyroid condition required continuous medication including Levothyroxine and Polyethylene Glycol (constipation). Id. The Veteran's weight history between November 2014 and January 2015 was 127.3 pounds (lbs.) on November 2014, 126 lbs. in December 2014, and131 lbs. in January 2015. See January 2015 VA Psychiatric Treatment Note, Patent Weight History in CAPRI received January 2016. In a March 2015 Rating Decision, the RO granted service connection for her thyroidectomy scar and assigned a noncompensable rating. In March 2017, the Veteran was provided another VA examination for her thyroid condition. See March 2017 VA Thyroid and Parathyroid Conditions DBQ. The Veteran reported that she continues to take thyroid replacement medication and has had residual constipation since the last VA examination in December 2014. She also endorsed hot and cold chills along with memory loss. Id. The Veteran's symptoms include constipation, mental sluggishness, slowing of thought, and cold intolerance. The examiner also confirmed that the Veteran's medications included thyroid replacement and laxative for constipation. Id. The Veteran weighed 141 lbs. in December 2019. See December 2019 VA Internal Medicine Outpatient Note in CAPRI received September 2020. The Veteran's weight in February 2020 was 135 lbs. See February 2020 VA Primary Care Outpatient Note in CAPRI received September 2020. The VA physician noted she was last seen in 2019 and has had two babies in the last two years. Id. The Veteran testified that she experienced symptoms of fatigue, constipation, and difficulty with short term memory due to her thyroid condition during the January 2021 Board hearing. Analysis Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran is entitled to a 30 percent disability rating for hypothyroidism for the entire period on appeal. Rating Criteria Prior to December 10, 2017 The Veteran's symptoms manifested as constipation, fatigability, mental sluggishness, and hot flashes. Essentially the Veteran's overall disability picture more nearly approximates hypothyroidism involving fatigability, constipation, and mental sluggishness. See December 2014 VA Thyroid and Parathyroid Conditions DBQ. Thus, a rating of 30 percent is warranted under criteria prior to November 2, 2017. However, a 60 percent rating is not warranted because there was no evidence that the Veteran experienced muscular weakness, mental disturbance, or weight gain due to her hypothyroidism. Specifically, during the VA examinations in March 2012, December 2014, and March 2017, the Veteran did not endorse any symptoms of muscle weakness or weight gain. In fact, during the December 2010 VA examination, the Veteran reported weight loss. See December 2010 VA Thyroid and Parathyroid Disease Examination. She also denied any weight change during the October 2013 VA dermatology consult. Additionally, the Veteran's weight history between November 2014 and January 2015 was 127.3 pounds (lbs.) on November 2014, 126 lbs. in December 2014, and131 lbs. in January 2015. See January 2015 VA Psychiatric Treatment Note, Patent Weight History in CAPRI received January 2016. The Board also notes her most recent weight was 135 lbs. in February 2020 which following having two babies. See February 2020 VA Primary Care Outpatient Note in CAPRI received September 2020. As such, the evidence does not demonstrate any significant weight gain due to hypothyroidism. Although the Veteran reported symptoms of depression, the Veteran also has been diagnosed with acquired psychiatric disability including major depressive disorder. Notably, during the VA psychiatric examinations of record attributed her depression to traumas she experienced during service rather than due to her thyroid condition. See i.e., March 2020 Private Review PTSD Disability Benefits Questionnaire (DBQ). As such, the evidence does not demonstrate that depression was associated with her thyroid condition. Based on the foregoing, the Board finds that the 60 percent rating criteria has not been met. The Veteran's thyroid condition does not meet the criteria for a 100 percent rating because she did not have muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. As discussed above, the Veteran did not report muscle weakness during the appeal period and depression was characterized an acquired physiatric disability which was linked to her in service trauma. Also, although the Veteran testified that she had difficulty with short term memory during the January 2021 Board hearing, there is no evidence that she experienced dementia or slowing of thought. She did not report any cardiovascular problems or bradycardia. The Board considered the Veteran's reports of cold intolerance during December 2014 and March 2017 VA examinations. However, her assertions are not supported by the record. Notably, the Veteran routinely sought follow-up care for hypothyroidism for medication and the weight of the evidence shows that she did not report cold intolerance to physicians during the appeal period. For instance, in October 2013, the Veteran denied any fever or chills. See October 2013 VA Dermatology Note in CAPRI received March 2014. The evidence weighs against finding that hypothyroidism manifested as cold intolerance. The Board also notes the Veteran endorsed sleepiness once during the appeal period in December 2014. See December 2014 VA Thyroid and Parathyroid Conditions DBQ. However, such does not rise to the level of severity required for a 100 percent rating because she did not have reoccurring episodes of sleepiness. The Board finds that the preponderance of the evidence is against a finding that the Veteran's condition merits a 60 or 100 percent rating for hypothyroidism under the former rating criteria. VA and private treatment providers consistently noted no cardiovascular illnesses, including brachycardia, throughout the period on appeal. Based upon a review of the relevant medical record, the Board finds the preponderance of the evidence weighs against an award of a 60 or a 100 percent disability rating. Rather, the evidence more nearly approximates a rating of 30 percent. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. After December 10, 2017 The Veteran's thyroid condition warrants a 30 percent rating under the current rating criteria because it is best characterized as hypothyroidism without myxedema. The Veteran's VA treatment records do not mention a hypothyroidism with myxedema. Additionally, as noted above the symptoms associated with myxedema such as cold intolerance, muscle weakness and mental disturbance have not been demonstrated. Under the current version of the criteria, effective December 10, 2017, a 100 percent rating requires a thyroid condition manifested myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)), but only for a period of six months after an examiner has determined that the condition has stabilized. Thereafter, the residual effects of hypothyroidism are to be rated under the appropriate diagnostic code(s) within the appropriate body system(s) (e.g., eye, digestive, and mental disorders). 38 C.F.R. § 4.119, DC 7903. Here, as discussed above, since there is no evidence of myxedema, it follows that there was no crisis following which an examining physician would need to determine that there has been stabilization, warranting an increased 100 percent rating, for a period of six months after an examiner has determined the condition to be stabilized. At no point during this period, have any residuals warranted rating under the appropriate body system and subsequent diagnostic code(s) within the appropriate body systems (e.g., eye, digestive, and mental disorders) such that an increased 100 percent rating is not warranted under the updated Diagnostic Code 7903. Based upon a review of the relevant medical record, the Board finds the preponderance of the evidence weighs against an award of a 60 or a 100 percent disability rating under the old and new rating criteria. Rather, the evidence more nearly approximates a rating of 30 percent for the entire period on appeal. Accordingly, resolving reasonable doubt in the Veteran's favor, the Board grants a 30 percent rating for the entire period on appeal. REASONS FOR REMAND 1. Lumbar spine strain is remanded. Upon review, the Board finds that a remand is necessary for the Veran's lumbar spine disability because the March 2017 and September 2020 VA examination reports are inadequate under the holdings of Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). The March 2017 VA examiner did not provide the specific or estimated results of active range of motion (ROM), passive ROM, weightbearing ROM, and non-weightbearing ROM or detailed explanation for why ROM testing could not be conducted for the Veteran's lumbar spine disability. See March 2017 VA Back Conditions DBQ. As such, the March 2017 VA examination does not comply with the requirements of Correia v. McDonald, 28 Vet. App. 158 (2016). Regarding Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Veteran endorsed flare-ups during March 2017 and December 2020 VA examinations. See September 2020 VA Back Conditions DBQ; March 2017 VA Back Conditions DBQ. However, the VA examiners failed to provide an estimated ROM or functional loss during flare-ups, or provide an estimation of the severity, frequency, duration, and functional loss manifestations during a flare-up. As such, a remand is necessary to obtain a VA medical opinion that complies with the holding in Sharp. In light of Correia and Sharp, a retrospective opinion is necessary to address the necessary ROM findings and the Veteran's functional loss due to flare-ups. Thus, on remand, a retrospective medical opinion his lumbar spine disability for the period from October 23, 2013 until the present is necessary. See Chotta v. Peake, 22 Vet. App. 80, 85 (2008). During the January 2021 Board hearing the Veteran testified that she was provided with specialized chair, keyboard, and mouse due to her lumbar spine disability. The VA examiner should address the Veteran's functional impairment to include the need for special equipment. The Board also notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See 85 Fed. Reg. 76453. The Veteran may be entitled to higher or separate ratings for neurological symptoms under the new rating criteria. As such, the VA examiner should address the new rating criteria beginning February 7, 2021. Therefore, based on these new regulations, the Veteran should be afforded a new VA examination that addresses these new criteria. 2. Pilonidal cyst A remand is necessary to ascertain the current nature and severity of the Veteran's service-connected pilonidal cyst. During the January 2021 Board hearing, the Veteran testified that pilonidal cyst has increased in severity since her last VA examination in in March 2017. Specifically, the Veteran reported extremely painful abscesses associated with her pilonidal cysts, which reoccur approximately every three months. See Hearing Transcript. The Veteran also endorsed flare-ups, which resulted in 10 out 10 pain and caused limitation of motion in standing, sitting and walking. Based on the Veteran's competent and highly credible assertions, the Board finds that the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of her pilonidal cyst. Evidence of a change in the condition or allegation of worsening of the condition renders an examination inadequate for rating purposes. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Thus, due to the Veteran's reports of worsening of her condition, a remand is necessary to obtain a VA examination to determine the current severity of the Veteran's service-connected pilonidal cyst. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. In correspondence dated February 2021, the Veteran indicated that she was recently diagnosed with hidradenitis suppurativa. See February 2021 Correspondence. The Board notes that hidradenitis suppurativa may be a related to or co-existing condition to her service-connected pilonidal disease. See Ngan, Vanessa, DermNet, Pilonidal Disease, https://dermnetnz.org/topics/pilonidal-disease/ (last visited May 7, 2021). As such, the VA examiner should address the relationship between pilonidal cysts and hidradenitis suppurativa. The Board notes the claims file reflects that the Veteran has been receiving treatment from the St. Louis VA Medical Center (VAMC) and Denver VAMC to include the Lindstrom VA Clinic, and that records dated through September 2020 are associated with the file; however, more recent records may exist. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016). The matters are REMANDED for the following action: 1. Obtain the Veteran's comprehensive VA treatment records for the period from September 2020 to the present, to include from VA medical centers, clinics, counseling centers, hospitals, and outpatient treatment centers. See 38 C.F.R. § 3.159(c)(3) (2020). The Board observes that the Veteran has been treated at various VA facilities, to include Denver VAMC, St. Louise VAMC, and Lindstrom VA Clinic. A request from these facilities should be accomplished. 2. The Board recognizes the potential practical difficulties in scheduling an examination in light of the COVID-19 epidemic and requests flexibility and understanding in affording the Veteran any warranted examination. 3. Request the Veteran to resubmit colored copies, as photographs submitted in January 2021 are blurred. Lumbar Spine Disability 4. After the foregoing development has been completed, obtain an addendum, medical opinion to determine the severity of the Veteran's lumbar spine disability. The examiner should provide a full description of the Veteran's associated functional impairments as they relate to the relevant rating criteria. 5. The examiner should review the claims file including this Remand. If the examiner determines an opinion cannot be provided without an examination, the examiner should conduct any studies and/or tests deemed necessary (including imaging studies and range of motion testing, which would include pain on both active and passive motion, in weight-bearing and non-weight-bearing, and, if possible, with the range of the opposite undamaged joint), the examiner should fully describe all symptomatology and functional deficits associated with his lumbar spine disability. 6. The examiner is specifically asked to set forth the extent of any functional loss due to weakened movement, excess fatigability, incoordination, pain on use, swelling, deformity, or atrophy of disuse. 7. The examiner shall inquire as to periods of flare-ups and note the frequency and duration of any such flare-ups. ANY ADDITIONAL IMPAIRMENT ON USE OR IN CONNECTION WITH FLARE-UPS SHOULD BE DESCRIBED IN TERMS OF THE DEGREE OF ADDITIONAL RANGE OF MOTION LOSS. THE EXAMINER SHOULD SPECIFICALLY DESCRIBE THE SEVERITY, FREQUENCY, AND DURATION OF FLARE-UPS; NAME THE PRECIPITATING AND ALLEVIATING FACTORS; AND ESTIMATE, PER THE VETERAN, TO WHAT EXTENT, IF ANY, SUCH FLARE-UPS AFFECT FUNCTIONAL IMPAIRMENT. If it is the examiner concludes that he or she cannot feasibly provide the requested opinion(s), even considering all of the available evidence, it must be so stated, and the examiner must provide the reasons why offering such opinion(s) is not feasible. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of the need for additional information, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to a particular question. 8. THE EXAMINER SHOULD ALSO REVIEW THE MARCH 2017 AND SEPTEMBER 2020 VA EXAMINATIONS, AND PROVIDE A RETROSPECTIVE OPINION AS TO THE VETERAN'S FLARE-UPS BASED ON THE AFOREMENTIONED (SHARP). IF UNABLE TO PROVIDE THIS RETROSPECTIVE TESTING, THE EXAMINER SHOULD STATE WHY AND PROVIDE A REASONED EXPLANATION FOR THE DETERMINATION. 9. THE EXAMINER SHOULD ALSO REVIEW THE JANUARY 2015 AND JANUARY 2018 VA EXAMINATIONS, AND PROVIDE A RETROSPECTIVE OPINION AS TO THE VETERAN'S FLARE-UPS BASED ON THE AFOREMENTIONED (SHARP). IF UNABLE TO PROVIDE THIS RETROSPECTIVE TESTING, THE EXAMINER SHOULD STATE WHY AND PROVIDE A REASONED EXPLANATION FOR THE DETERMINATION. 10. The examiner must provide all information required for rating purposes, including pursuant to the "new" rating criteria (effective February 7, 2021). 11. To the extent possible, the examiner should identify any symptoms and functional impairments due to the lumbar spine disability, and discuss the effect of the Veteran's disabilities on any occupational functioning and activities of daily living. The examiner is asked to address the Veteran's use of specialized work equipment including chair, keyboard, and mouse due to her lumbar spine disability. Pilonidal Cyst 12. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected pilonidal cyst. 13. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the appropriate rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. 14. The examiner must address the Veteran's testimony (page 18-21 of January 2021 Hearing Transcript) as to the severity of the disability, to include limitation of motion, flareups every 2 to 3 months, assessment of pain, description of, and location of the cysts in the groin area. 15. Estimate how much of the entire body was affected and how much total exposed area was affected by the Veteran's pilonidal cysts. 16. Identify any steroidal topical medication prescribed to treat the pilonidal cyst during the appellate period and whether such the use of topical steroidal medication constituted systemic therapy. 17. For each topical non-steroidal medication for the treatment of dermatophytosis that are "like" a corticosteroid or other immunosuppressive drug, provide an opinion as to whether each constitutes systemic therapy. Systemic therapy is defined as a therapy that affects the body as a whole. In answering this question, the VA examiner must discuss the method by which the topical treatment works, as well as any known side effects. A complete rational must be provided for each conclusion provided. 18. The examiner is asked to address the Veteran's recent diagnosis of hidradenitis suppurativa and its relationship to her service-connected pilonidal cyst. The examiner should also differentiate the symptoms of hidradenitis suppurativa and pilonidal cyst. 19. To the extent possible, the examiner should identify any symptoms and functional impairments due to pilonidal cyst alone and discuss the effect of the Veteran's pilonidal cyst on any occupational functioning and activities of daily living. 20. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). A rationale for all opinions expressed should be provided in the examination report. If medical literature is relied upon in rendering any opinion(s), the VA examiner should identify and specifically cite each reference material utilized. 21. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Lilly, 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.