Citation Nr: 21031572 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 15-35 540A DATE: May 24, 2021 ORDER Entitlement to a 70 percent rating from November 26, 2010 to June 14, 2014 is granted for anemia, subject to the laws and regulations governing the payment of monetary awards. Entitlement to a rating in excess of 10 percent from June 14, 2014 to March 3, 2020 for anemia is denied. Entitlement to a 30 percent rating from March 3, 2020 for anemia is granted, subject to the laws and regulations governing the payment of monetary awards. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities from March 21, 2014 to June 14, 2014 and from May 24, 2016 is granted, subject to the laws and regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for a right knee disability, to include as secondary to a service-connected disability is remanded. Entitlement to TDIU from June 14, 2014 to May 24, 2016, to include on an extraschedular basis, is remanded. FINDINGS OF FACT 1. From November 26, 2010 to June 14, 2014 the Veteran's anemia was manifested in a hemoglobin level of 7gm/100ml or less, with findings such as dyspnea on mild exertion, cardiomegaly, tachycardia, or syncope. 2. From June 14, 2014 to March 3, 2020 the Veteran's anemia did not manifest in a hemoglobin level of 8gm/100ml or less with findings such as weakness, easy fatigability, headaches, lightheadedness, or shortness of breath; and the Veteran did not require intravenous iron infusions 4 or more time per 12 month period. 3. From March 3, 2020, the Veteran's anemia required intravenous iron infusions 4 or more time per 12 month period. 4. Effective March 21, 2014 to June 14, 2014 and from May 24, 2016, the Veteran meets the schedular criteria for TDIU, and her service-connected disabilities prevent her from engaging in substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a 70 percent for anemia prior from November 26, 2010 to June 14, 2014 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.21, 4.7, 4.117 Diagnostic Code (Code) 7700. 2. The criteria for a rating in excess of 10 percent for anemia from June 14, 2014 to March 3, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.21, 4.7, 4.117 Diagnostic Code (Code) 7700, 7720. 3. The criteria for a 30 percent for anemia prior from March 3, 2020 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.21, 4.7, 4.117 Diagnostic Code (Code) 7720. 4. For the periods from March 21, 2014 to June 14, 2014 and from May 24, 2016, the criteria for an award of TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.40, 3.41, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1980 to April 1989. This issue of service connection for a right knee disability was most recently before the Board in December 2019 when it was remanded for further development. In February 2021, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge regarding all the above issues. A transcript of that hearing is of record In a December 2020 rating decision the rating of the Veteran's anemia was increased from 10 percent to 30 percent, effective August 12, 2020. As the maximum schedular rating for anemia has not been awarded for the entire period on appeal, and the Veteran has not expressed satisfaction with the ratings, the appeal continues. AB v. Brown, 6 Vet. App. 35 (1993). Increased Rating The Veteran seeks higher ratings for her service-connected anemia. Her service-connected anemia is rated as noncompensable (0 percent) from April 12, 1989; 10 percent from January 20, 2010; 30 percent from November 26, 2010, and; 10 percent from December 1, 2010 under 38 C.F.R. § 4.117 Code 7700. The anemia is evaluated as 30 percent from August 12, 2020 under Code 7720. The Board notes that the Veteran was hospitalized for treatment for anemia in November 2010. She filed a formal claim for a higher rating in July 2011. Under VA regulations in effect prior to March 2015, a report of examination or hospitalization will be accepted as an informal claim for benefits. 38 C.F.R. § 3.157 (2014). Accordingly, the Board will consider the November 2010 hospitalization to be an informal claim, and the period on appeal will be from that date. Disability ratings are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate Codes identify the various disabilities. 38 C.F.R. § Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). During the pendency of this appeal, the provisions of 38 C.F.R. § 4.117 were amened, effective December 9, 2018. The rating criteria for anemia was revised by removing Code 7700 (Anemia, hypochromic-microcytic and megaloblastic, such as iron-deficiency and pernicious anemia) and adding separate diagnostic codes (Codes 7720-7723) for the four major types of anemia that are neither hereditary nor secondary (addressed under the diagnostic code for the causative condition). See 83 Fed. Reg. 54254 (October 29, 2018). The Board will consider the Veteran's claim under both the old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. If the new criteria are more favorable, they will only be applied from August 13, 2018, when the regulations became effective. Under the relevant former criteria, Code 7700 provides that a 10 percent rating is warranted for a hemoglobin level of 10 gm/100ml or less with findings such as weakness, easy fatigability, or headaches. A 30 percent rating is warranted for a hemoglobin level of 8 gm/100ml or less, with findings such as weakness, easy fatigability, headaches, lightheadedness, or shortness of breath. A 70 percent rating is warranted for a hemoglobin level of 7 gm/100 ml or less, with findings such as dyspnea on mild exertion, cardiomegaly, tachycardia (100 to 120 beats per minute) or syncope (three episodes in the last six months). A 100 percent rating is warranted for a hemoglobin level of 5 gm/100 ml or less, with findings such as high output congestive heart failure or dyspnea at rest. 38 C.F.R. § 4.117 (2018), Code 7700. Under the current criteria, anemia is rated under Code 7720, iron deficiency anemia. Under Code 7720 iron deficiency anemia requiring intravenous iron infusions 4 or more times per 12-month period warrants a maximum 30 percent rating, while iron deficiency anemia requiring intravenous iron infusions at least 1 time but less than 4 times in a 12-month period, or requiring continuous treatment with oral supplementation provides a 10 percent rating. A noncompensable rating is provided for asymptomatic iron deficiency anemia or requiring treatment only by dietary modification. 38 C.F.R. § 4.117 (2019), Code 7720. The Board "may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria." Jones v. Shinseki, 26 Vet. App. 56 (2012). Under the relevant former criteria under 38 C.F.R. § 4.117, Code 7700 does not explicitly contemplate the ameliorative effects of medication, therefore, an evaluation under that Code should contemplate severity of the Veteran's anemia symptoms which would occur without medication. In November 2010, the Veteran was admitted to a VA hospital requiring a blood transfusion for her service-connected anemia. Her admission note indicated that her hemoglobin level on November 26 was 6.6 gm/100ml and 6.5 gm/100ml on admission. She also had symptoms of dyspnea on exertion, chest pain, lightheadedness, weakness and fatigue worsening over the last 2 months. She was discharged later in December 2010 after a blood transfusion. On discharge her hemoglobin level was 9.7 gm/100 ml. On September 2011 VA examination, the examiner noted that the Veteran's iron deficiency anemia had required continuous medication for control as she had last had an iron infusion in May 2011, but was not currently undergoing treatment and had no further infusions scheduled. She did not have thrombocytopenia or require treatment of transfusions of platelets or red blood cells. Her symptoms including easy fatigability, light-headedness, shortness of breath, headaches, dyspnea on mild exertion, and tachycardia. On laboratory testing, hemoglobin level was 10.8 gm/100ml. The examiner opined that her anemia did not impact her ability to work. On August 2012 VA examination, the examiner noted that continuous medication was not required to control her anemia, but she received weekly ferric gluconate infusions. Her symptoms included weakness, easy fatigability, and dyspnea on mild exertion. On laboratory testing, hemoglobin level was 10.7 gm/100ml. The examiner opined that her anemia impacted her ability to work it impacted her ability to stand for 5 minutes, walk a flight of steps, or walk 1 to 2 blocks. On June 2014 VA examination, the Veteran reported she had been treated with oral iron, but it was not successful at bringing up her hematocrit and she was started on iron infusions. The examiner found her anemia was in remission and she was watching it. The examiner noted she had had blood transfusions, but none in the previous 12 months. She did not have any symptoms of anemia. On laboratory testing, hemoglobin level was 12.9 gm/100ml. The examiner opined that her anemia did not impact her ability to work. In a September 2015 rating decision, staged ratings were assigned for the Veteran's anemia. A 10 percent rating was assigned January 20, 2010, a 30 percent rating from November 26, 2010, and a 10 percent was assigned from December 1, 2010. The Veteran's VA treatment records reflect that from the June 2014 VA examination through February 2020, the Veteran's anemia was stable and no symptoms were noted, but was being monitored. In a March 2020 VA treatment note, the Veteran reported that using oral iron for anemia had not worked and weekly iron infusions for 6 weeks was ordered. On November 2020 VA examination, the Veteran reported her anemia had worsened since onset during service. The examiner noted the Veteran required continuous medication, ongoing iron infusions, for control of her anemia. The Veteran's iron deficiency anemia required intravenous iron infusions 4 or more times in the prior 12 months. She had no other symptoms related to her anemia. On laboratory testing, hemoglobin level was 11.6 gm/100ml. The examiner opined that her anemia impacted her ability to work as alternating physical activities with periods of rest, and shortened work hours or work week might be necessary, but it depended on the severity of her symptoms. In a December 2020 rating decision, the rating was increased from 10 percent to 30 percent, under new Code 7720, effective August 12, 2020. The Agency of Original Jurisdiction (AOJ) cited that as the date of a claim filed during the period on appeal. At the February 2021 videoconference hearing, the Veteran testified that she was hospitalized from November to December 2010 where she required a blood infusion. She testified that her symptoms had been the same throughout the entire appeals period. Additionally, VA treatment records throughout the period on appeal refect treatment for anemia and routine laboratory testing for hemoglobin levels following her November 2010 hospitalization. During this period, the lowest hemoglobin level was 9.2 gm/100ml in October 2013. Based on a review of the record, the Board finds that entitlement to a 70 percent rating, but no higher, is warranted for anemia from November 26, 2010 to June 14, 2014; a 30 percent rating is warranted from March 3, 2020; a rating higher than 10 percent is not warranted from June 14, 2010 to March 3, 2020. For the period from November 26, 2010 to June 14, 2014 the Board finds a higher 70 percent rating is warranted. The Veteran was hospitalized for a blood transfusion from November 26, 2010 to December 1, 2010, and on admission to the VA hospital, the Veteran's hemoglobin level was 6.6 gm/100ml and she experienced symptoms of dyspnea on exertion, chest pain, lightheadedness, weakness and fatigue. While on discharge from the hospital, her hemoglobin level was 9.7 gm/100ml, and it would not drop lower than 9.2 gm/100ml during any period on appeal, the record reflects that the Veteran's anemia was continuously treated by medication and iron infusions, and the Board may not consider the ameliorating effects of such medication. See Jones, 26 Vet. App. at 56. Accordingly, the Veteran's hemoglobin levels during this period may not be an accurate reflection of the severity of the Veteran's symptoms during this period. As such, affording the Veteran the benefit of the doubt, entitlement to a 70 percent rating, and no higher, from November 26, 2010 to June 14, 2014 as the record reflects the Veteran experienced symptoms such as dyspnea on mild exertion during this period, which is specifically contemplated by the 70 percent rating. A higher 100 percent rating is not warranted for this period, even not taking into account that her hemoglobin level was not 5gm/100 ml or less during this period as she did not have congestive heart failure or dyspnea at rest at any point during this period. For the period from June 14, 2014 to March 3, 2020, the Board finds that the criteria for a rating in excess of 10 percent are not met or more closely approximated. During this period, the Veteran's anemia was not continuously treated, and no medication was noted until the March 2020 VA provider noted the Veteran had unsuccessfully taken oral iron medication. At no point during this period, the Veteran's hemoglobin level hemoglobin level 8gm/100 ml or less, and she had no symptoms of her anemia. Additionally, a rating in excess of 10 percent is not warranted under Code 7720, which was effective December 9, 2018. While the Veteran reported taking iron orally, at no point during this period was the Veteran's anemia shown to have required any intravenous iron infusions. The Board finds that a higher 30 percent rating, the highest rating available under Code 7720 is warranted from March 3, 2020. The March 2020 VA treatment note indicated that taking iron orally did not work and the provider ordered weekly iron infusions for 6 weeks. Accordingly, providing the Veteran the benefit of the doubt, March 3, 2020, the date of the VA treatment note is the earliest date at which her anemia required 4 or more intravenous iron infusion in a 12 month period, and a 30 percent rating is warranted from that date. A rating higher than 30 percent is not warranted under Code 7700 as the November 2020 VA examiner noted that the Veteran had no additional symptoms of anemia, and findings such as dyspnea on mild exertion, cardiomegaly, tachycardia, or syncope were not noted during this period. The Board has also considered the Veteran's lay statements that her anemia is worse than currently evaluated. She is competent to report symptoms because this requires only personal knowledge as it comes to her through her senses. Layno v. Brown, 6 Vet. App. 465 (1994). She is not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disabilities has been provided by the medical personnel who have examined her during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which such distinctively diagnosed disabilities are evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective complaints of increased symptomatology. TDIU The Board finds that entitlement to TDIU is warranted for the period from March 21, 2014 to June 14, 2014 and from May 24, 2016. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341 (a). In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). During the period on appeal, the Veteran's service-connected disabilities are pes planus, rated as 30 percent from September 10, 2013, 50 percent from May 24, 2016, 100 percent from June 15, 2017, 50 percent from December 1, 2017, 100 percent from August 3, 2018, 50 percent from October 1, 2018, 100 percent from April 26, 2019, and 50 percent from August 1, 2019; total hysterectomy rated as 30 percent from March 1, 2003 to December 1, 2019; right salpingo-oophorectomy rated as 10 percent from April 12, 1989 and as 30 percent from December 1, 2019; anemia in accordance with this decision rated as 10 percent from January 20, 2010, 70 percent from November 26, 2010, 10 percent from June 14, 2014, and 30 percent from March 3, 2020; right ankle tendonitis rated as 10 percent from May 24, 2016 and 20 percent from August 12, 2020; hemorrhoids rated as noncompensable (0 percent) from April 12, 1989; post-op residuals, lysis and excision of adhesions and left fimbrioplasty rated as noncompensable (0 percent) from April 12, 1989; scars right foot rated as noncompensable (0 percent) from October 31, 2017; and scars left too rated as noncompensable (0 percent) from August 3, 2018. Accordingly, the schedular criteria for TDIU are met from November 26, 2010 to June 14, 2014 and beginning May 24, 2016, the first date she had a disability rated at over 40 percent. 38 C.F.R. § 4.16 (a)(2). The issue of TDIU is moot for the period of the temporary total ratings from June 15, 2017 to December 1, 2017, from August 3, 2018 to October 1, 2018, and from April 26, 2019 and August 1, 2019. See Herlehy v. Principi, 15 Vet. App. 33 (2001). The fact that a veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the Veteran, because of service-connected disability, is incapable of performing the physical and mental acts required by employment, not whether she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In making its determination, VA considers such factors as the extent of the service-connected disabilities, and employment and educational background. 38 C.F.R. §§ 4.16 (b), 4.19. On August 2012 VA examination, the Veteran's anemia symptoms included weakness, easy fatigability, and dyspnea on mild exertion. The examiner opined that her anemia impacted her ability to work it impacted her ability to stand for 5 minutes, walk a flight of steps, or walk 1 to 2 blocks. In her March 2015 application for TIDU, the Veteran reported her pes planus, depression, and anemia prevented her from securing or following any substantially gainful occupation. She reported she had last worked full time in January 2009, when she became too disable to work, and had worked as a United States Post Office postal worker. She reported she had 1 year of college. In a May 2015 response for employment information, the United States Office of Personnel Management reported that the Veteran had last work for the United States Post Office in March 2014, when she was removed from her position. Her employer reported she had lost 4 months and 3 days due to her disability in the prior 12 months. On October 2016 VA pes planus examination, the examiner noted the Veteran constantly used a brace for her right ankle to prevent excessive pronation and orthotics for both feet. The examiner opined that the Veteran's pes planus impacted her ability to work. The examiner noted that the Veteran was a former letter carrier for the US Postal Service, retiring in 2008 and that her severe flatfeet and foot symptoms affected her tolerance to weight-bearing when she worked, often causing her to take breaks due to pain. The examiner also noted that she currently volunteered working with homeless Veterans for 32 hours a week. She tolerated her volunteer work "okay" but frequently took breaks to get off her feet and rest. On December 2016 VA right ankle examination, the examiner opined that the Veteran's right ankle disability impacted her ability to perform any type of occupational task as it resulted in decreased mobility. On May 2018 VA pes planus examination the Veteran reported that due to the pain in her feet, she could only walk 1/4 of a mile and stand for 20 minutes. She also reported she was unbalanced. The examiner opined that the Veteran's pes planus impacted her ability to perform any time of occupational task because she had limitation with walking, standing, and weight bearing due to pain and incoordination. On February 2019 VA pes planus examination, the Veteran reported having pain to both feet and balance problems in her right foot. She reported she used a cane to walk due to foot pain. The examiner opined that the Veteran's pes planus impacted her ability to perform any time of occupational task because she had decreased standing and decreased mobility. On April 2019 VA ankle examination, the Veteran reported having flare ups of her ankle disability during which pain made it hard for her to stand or walk for long periods of time. The examiner opined that the Veteran's ankle disability impacted her ability to perform any time of occupational task because it results in the need to minimize prolonged standing or walking, and that she needed to be allowed to sit if necessary. On November 2020 VA ankle examination, the Veteran reported that she regularly used a cane and brace for her right ankle disability. The examiner opined that the Veteran's ankle disability impacted her ability to perform any time of occupational task because the use of her foot in driving was prohibited until she returned to full weight bearing in regular shoos. Restrictions also included limited weight-bearing, and limitation of walking, climbing, and squatting would be limited early in her employment. On November 2020 VA anemia examination, the examiner opined that her anemia impacted her ability to work as alternating physical activities with periods of rest, and shortened work hours or work week might be necessary, but it depended on the severity of her symptoms. At the February 2021 hearing, the Veteran testified that she had last worked fulltime in 2008, when she worked as a letter carrier, where she had worked since 1992. She testified that she stopped working because she was told she had carpal tunnel syndrome in her hands. She also testified that her service-connected feet impacted her ability to work as she had balance issues and difficulty standing. She described she could only stand for about 5 to 10 minutes and walk for only about 10 minutes before having to take a break. She testified that she had 2 years of college and had tried volunteering through VA vocational rehabilitation program from about 2014 to 2016, but her service-connected disabilities impacted her ability to volunteer. The ultimate question of whether a Veteran is capable of securing or following substantially gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). The Board finds that the Veteran's service-connected disabilities precluded her from being able to maintain substantially gainful employment from March 21, 2014 to June 21, 2014 and from May 24, 2016. The schedular criteria for TDIU are met for the period from November 26, 2010 to June 14, 2014, however, probative evidence of record does not reflect that the Veteran was unemployed until March 2014. While the Veteran reported that she had last worked in either 2008 or 2009, her employer indicated that she had last worked in March 2014. The Board gives more probative weight to the employment records of her employer and finds that she has been unemployed since March 21, 2014. Her work history as a mail carrier involved physical activities, including walking and standing for long periods of time. The August 2012 VA examiner indicated her anemia impacted her ability to walk more 1 or 2 blocks. Additionally, from May 2016, VA examiners for her service-connected pes planus and right ankle disabilities found that such disabilities resulted in limiting her ability to walk or stand for long periods. Additional both the November 2020 and February 2021 VA anemia examiners indicated that the Veteran's anemia required her to have periods of rest and possibly shorten her workday or week. Accordingly, and resolving any reasonable doubt in the Veteran's favor, the Board finds that the Veteran has been precluded from securing and following gainful employment due to her service-connected disabilities, and TDIU is warranted for the periods from March 21, 2014 to June 14, 2014 and from May 24, 2016. REASONS FOR REMAND Entitlement to service connection for a right knee disability, to include as secondary to a service-connected disability is remanded. Unfortunately, there has not been substantial compliance with the Board's previous remand directives regarding the issue of service connection for a right knee disability. The January 2020 VA examiner's opinion obtained on remand is inadequate because the examiner used the wrong standard for aggravation; beyond natural progression, rather than the correct "any increase" in disability. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439 (1995). Accordingly, a new opinion on remand is necessary. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to TDIU from June 14, 2014 to May 24, 2016, to include on an extraschedular basis, is remanded. As noted above, the Veteran's service-connected disabilities do not meet the schedular requirements for TDIU under 38 C.F.R. § 4.16 (a) for the period from June 14, 2014 to May 24, 2016. The Board notes that it may only award TDIU on the first instance on a schedular basis. The record reflects that the Veteran's service-connected disabilities impacted her ability to work for the period from June 14, 2014 to May 24, 2016. Accordingly, the claim for TDIU from June 14, 2014 to May 24, 2016 should be referred to VA's Director of Compensation Service for extraschedular consideration under 38 C.F.R. § 4.16 (b); Bowling v. Principi, 15 Vet. App. 1 (2001). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the VA examiner who provided January 2020 VA opinion, (or another appropriate provider if January 2020 examiner is unavailable) to determine the nature and likely etiology the Veteran's right knee disability. Copies of all pertinent records must be made available to the examiner for review. If the examiner determines that an opinion cannot be provided without an examination, (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) one should be scheduled. Based on the review of the record (and examination if needed), the examiner should answer the following: Is it at least as likely as not that the Veteran's currently diagnosed left knee disability is (i) caused or (ii) aggravated by (defined as any increase in disability) the Veteran's service-connected bilateral pes planus and/or right ankle disability? Why or why not? The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 2. Refer the Veteran's claim for TDIU for the period from June 14, 2014 to May 24, 2016 to VA's Director of Compensation Service for extraschedular consideration. 3. Confirm that the VA medical opinion provided comports with this remand, specifically that the standard for the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Eric Struening 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.