Citation Nr: 21040603 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 95-05 892 DATE: July 6, 2021 ORDER Entitlement to service connection for cellulitis, to include on a secondary basis, is granted. Entitlement to an initial compensable rating for bilateral hearing loss is denied. Prior to August 30, 2002, entitlement to an initial rating in excess of 10 percent disabling for dermatitis is denied. Effective August 30, 2002, entitlement to a rating in excess of 60 percent disabling for dermatitis is denied. Prior to June 18, 2002, entitlement to an initial rating in excess of 10 percent disabling for bronchitis is denied. Effective June 18, 2002, entitlement to a rating in excess of 30 percent disabling for bronchitis is denied. REMANDED Entitlement to service connection, to include on a secondary basis, for diabetes mellitus II is remanded. FINDINGS OF FACT 1. The Veteran's cellulitis has been shown to be etiologically related to his service-connected dermatitis. 2. During the period on appeal, the Veteran's bilateral hearing loss disability manifested no worse than level II hearing loss in the right ear, and no worse than level II hearing loss in the left ear. 3. Prior to August 30, 2002, the Veteran's dermatitis was manifested by intermittent manifestations including exfoliation and itching. His skin condition was not manifested by constant exudation or itching, or marked disfigurement. 4. Effective August 30, 2002, the Veteran has been in receipt of a 60 percent disability rating for dermatitis. This is the highest rating available under the pertinent diagnostic code. 5. The Veteran's bronchitis was not manifested by pulmonary function testing (PFT) results showing pre-or-post-bronchodilator FEV-1, FEV-1/FVC results less than 71 percent predicted, or DLCO less than 66 percent predicted. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for cellulitis have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 2. The criteria for an initial compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.10, 4.85, 4.86 DC 6100. 3. Prior to August 30, 2002, the criteria for an initial rating in excess of 10 percent disabling for dermatitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.118, DC 7806-7833 (1996-2002). 4. Effective August 30, 2002, the criteria for a rating in excess of 60 percent disabling for dermatitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.118, DC 7806-7833 (2002-2021). 5. Prior to June 18, 2002, the criteria for an initial rating in excess of 10 percent disabling for bronchitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.97, DC 6600. 6. Effective June 18, 2002, the criteria for a rating in excess of 30 percent disabling for bronchitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.97, DC 6600. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1989 to September 1993. This matter is before the Board of Veterans' Appeals (Board) on appeal from June 1994 and March 2002 (increased rating bronchitis), August 2007 (increased rating hearing loss), May 2012 (service connection - cellulitis), April 2017 (increased rating dermatitis), and May 2017 (service connection - diabetes) rating decisions by a Department of Veterans Affairs Regional Office (RO). By way of history, in a July 2003 Decision, the Board denied an initial rating in excess of 10 percent disabling for bronchitis. The Board additionally referred a claim for left leg cellulitis to the Agency of Original Jurisdiction (AOJ). With regard to the increased rating claim for bronchitis, the Veteran appealed the Board's decision to the U.S. Court of Appeals for Veterans Claims (Court). In an August 2005 Order, the Court vacated the Board's July 2003 Decision and remanded for readjudication in compliance with the Joint Motion for Remand (JMR). In pertinent part, the JMR found that the Board erred in finding that the duty to notify was satisfied as mandated by the Veterans Claims Assistance Act (VCAA). Thereafter, the Board remanded this matter in a May 2008 Decision for issuance of proper notice and a VA examination. The May 2008 Decision additionally remanded the increased rating claim for bilateral hearing loss for issuance of a statement of the case (SOC). A June 2009 rating decision granted an increased 30 percent evaluation for bronchitis effective June 18, 2002. In October 2010, the Board remanded the service connection claim for a skin condition, and the increased rating claims for bronchitis and bilateral hearing loss and instructed the AOJ to obtain VA examinations. In this regard, the Board noted that the prior VA examinations and private treatment records were insufficient for rating those claims. The claims were remanded again in a February 2012 Decision as none of the requested development was conducted. In January 2016, the Board remanded the increased rating claims for bilateral hearing loss and bronchitis, and the service connection claims for a skin condition and cellulitis, to obtain updated VA medical records and VA examinations. A subsequent February 2017 Board Decision remanded these claims again for issuance of a supplemental statement of the case (SSOC). Additionally, an April 2017 rating decision granted service connection for dermatitis, previously claimed as skin condition, and assigned an initial 10 percent evaluation effective September 6, 1993, and a 60 percent evaluation effective August 30, 2002, the date the rating criteria were amended. In a March 2018 Decision, the Board denied a compensable rating for bilateral hearing loss, and ratings in excess of 10 percent for bronchitis and dermatitis. The Veteran appealed the Board's decision to the Court. In an October 2018 Order, the Court vacated the March 2018 Decision and remanded for readjudication in compliance with the JMR. The JMR found that the Board relied on an inadequate May 2016 VA hearing loss examination, failed to consider extraschedular consideration for bronchitis, and erred in determining that cellulitis and dermatitis were closely related skin conditions in violation of the holding in Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). In an October 2018 Decision, the Board remanded the issue of entitlement to service connection for diabetes to obtain a VA examination. In May 2019, the Board remanded this case and instructed the AOJ to obtain VA hearing loss and skin examinations, and referred the increased rating claim for bronchitis to the Director of VA Compensation Service for extraschedular consideration. The Board notes that the requested VA examinations and extraschedular opinion have been obtained and associated with the claims file. Accordingly, after reviewing the actions of the AOJ, the Board finds there was substantial compliance with the requested development. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Lastly, in a November 2020 Decision, the Board remanded the service connection claim for diabetes to obtain another VA examination. That claim is addressed in the Remand section below. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). To prevail on the issue of entitlement to secondary service connection, there must be: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Cellulitis The Veteran asserts entitlement to service connection for cellulitis. Specifically, the Veteran asserts he developed cellulitis due to environmental exposure during service. Alternatively, he asserts that his cellulitis is secondary to his service-connected dermatitis. See February 1995 VA Form 9, September 2014 VA Form 9 and May 2017 Notice of Disagreement (NOD). The evidence of record includes the Veteran's service treatment records (STRs) including a May 1991 record noting the presence of a viral rash. The July 1993 separation examination noted the Veteran's right hand was hyperpigmented and a skin lesion was noted to be present between the right 2nd and 3rd digit the past 6 months. Post-service records show that in June 1994, the Veteran reported an intermittent itchy rash on both arms. He was assessed with raised lesions over the lateral aspect of the left arm and diagnosed with eczematous dermatitis. In September 1994, erythema and papules were noted on the forearm, finger and legs. In November 1996, a VA medical record noted a papular rash over the right elbow and the right ankle which was pruritic. He was assessed with dermatitis and treated with Diprolene and antifungal creams. See VA Medical Records Received March 2002. A March 2000 VA medical record noted an abcess on the left thigh which was very painful. He was assessed with cellulitis. The following day, more edema and erythema were noted. He was assessed with left thigh cellulitis. Another March 2000 medical record noted the Veteran was just discharged from the hospital after having severe staph cellulitis of the left thigh. See VA Medical Records Received December 2020. An April 2006 VA medical record noted moderate erythema over the right leg with multiple very small pustular rashes. The physician noted suspicions of early cellulitis. He was assessed with eczema with superimposed cellulitis. In May 2008, dermatitis and warmth on the skin of the bilateral leg was noted, as was a small area of erythema on the anterior aspect of the right leg. The Veteran was assessed with cellulitis. See VA Medical Records Received December 2020. An August 2008 VA general examination noted skin symptoms of itching and rashes. Bilateral lower leg excoriation and patches of hyperpigmented, very dry and scaling skin were currently observed. No current evidence of cellulitis was found. The Veteran was diagnosed with recurrent episodes of cellulitis of the bilateral leg, treated and resolved. A May 2012 VA medical record noted no evidence of cellulitis. The Veteran was assessed with onychomycosis and atopic dermatitis. See VA Medical Records Received December 2020. An April 2017 VA skin examination noted diagnoses for dermatitis and dermatophytosis. The Veteran reported a severe episode of dermatitis in 2000 which developed into cellulitis. He also reported recurrent episodes of cellulitis with the latest episode approximately two years prior. The examiner noted that a medical opinion "does not proceed because there is no evidence of an active, acute of chronic left leg cellulitis or residuals of left leg cellulitis." In addition, the examiner noted no evidence of any active leg cellulitis during active duty service. A March 2019 VA medical record noted a skin examination which found no signs of infection or proximal, distal or localized cellulitic changes. In September 2019, a VA medical record noted the Veteran was last admitted in 2017 for treatment for "cellulitis/septic." See VA Medical Records Received December 2020. The Veteran last underwent a VA skin examination in January 2020. Diagnoses for dermatitis, dermatophytosis and episodes of cellulitis were noted. The Veteran reported persistent skin rashes and itching, mostly on his arms, legs, groin, gluteales and back. He also reported intermittent episodes of cellulitis on areas of his dermatitis, with the most recent episode in March 2019. The examiner opined that the Veteran's cellulitis was not "at least as likely as not (50 percent or greater probability)" etiologically related to service. In support of this opinion, the examiner noted that the STRs did not show any evidence of recurrent signs, symptoms, diagnosis or treatment of cellulitis during active duty service. With regard to the documented episodes of cellulitis during the period on appeal, the examiner further opined that it was "at least as likely as not (50% or greater probability)" that the condition was proximately due to or the result of the service-connected dermatitis. In support of this opinion, the examiner noted that although there was no evidence of a visible active or chronic cellulitis found during the examination, the medical records did show multiple occasions in which he had been found to have, and was treated for, acute signs and symptoms of cellulitis. The examiner further noted medical literature that recognized that dermatitis was a chronic condition in which acute exacerbations caused inflammation and itching promoting self-scratching and lacerations that compromised a person's skin integrity. Based on the medical literature, the examiner found that the Veteran's dermatitis increased his risk for developing cellulitis. After a review of the evidence of record, the Board finds that entitlement to service connection for cellulitis is warranted. During the period on appeal, a March 2000 VA medical record noted diagnoses for cellulitis. Accordingly, as the Veteran has been shown to have been diagnosed with cellulitis during the period on appeal, the remaining question is whether his cellulitis is otherwise related to service. In this regard, the Board finds the January 2020 VA examination report the most probative evidence of record. The examiner considered the evidence, including intermittent episodes of cellulitis, and determined that it was "at least as likely as not" that the Veteran's cellulitis was proximately due to or the result of the service-connected dermatitis. The Board finds the examiner's rationale persuasive and well supported. Importantly, with regard to secondary service connection, there is no medical opinion to the contrary. The claim is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 2. Bilateral Hearing Loss The Veteran filed a service connection claim for hearing loss in April 1994. That claim was granted in an August 2007 rating decision and assigned a noncompensable rating effective September 6, 1993; the day following his separation from service. He has appealed the initial rating. The evidence of record includes November 1993 VA medical record noting a hearing test indicating moderate to severe sensorineural hearing loss, worse in the right ear. See VA Medical Records Received March 2002. The Veteran underwent a VA examination in February 1994. The examiner noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 10 25 35 LEFT 25 25 20 25 30 Speech recognition scores were 94 percent for the right ear and 96 percent for the left ear. These findings correlate to a designation of level I for the right ear, and level I for the left ear. Those results correspond to a non-compensable rating under DC 6100. A September 1994 audiological evaluation noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 70 70 70 70 70 LEFT 45 45 50 45 50 Speech recognition scores were 96 percent for the right ear, and 84 percent for the left ear. A review of the audiology report does not indicate whether the Maryland CNC word list was utilized. The Veteran reported that he had very little hearing in his right ear and that he had to ask people to frequently repeat themselves. He also reported difficulty using the telephone and that he could not hear female callers most of the time. See Medical Records Received March 2002. In October 2005, a VA medical record noted an examination of the ears which was negative for hearing loss. See VA Medical Records Received December 2020. Private medical records include a September 2008 audiological evaluation which noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 60 65 60 - 60 LEFT 35 40 35 - 45 Speech recognition scores were 92 percent for the right ear and 100 percent for the left ear. The record does not note whether the Maryland CNC word list was utilized. A September 2008 VA audiological assessment shows the Veteran complained of bilateral hearing loss, more pronounced in the right ear. The following audiometric testing results were noted: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 25 30 35 LEFT 15 15 10 15 25 Word recognition scores were 96 percent bilaterally. These findings correlate to a designation of level I for the right ear, and level I for the left ear. Those results correspond to a non-compensable rating under DC 6100. See VA Medical Records Received December 2020. In February and June 2009, a VA medical record noted an examination of the ears which was negative for hearing loss. See VA Medical Records Received December 2020. A July 2009 private audiological evaluation noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 65 60 60 - 70 LEFT 50 50 45 - 50 Speech recognition scores were 94 percent for the right ear and 100 percent for the left ear, although the record does not indicate whether the Maryland CNC word list was utilized. A September 2009 VA medical record noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 12 12 5 30 32 LEFT 14 18 8 10 8 Word recognition scores were 100 percent bilaterally. See VA Medical Records Received September 2009. These findings correlate to a designation of level I for the right ear, and level I for the left ear. Those results correspond to a non-compensable rating under DC 6100. In June and August 2011, VA medical records note examinations of the ears which were negative for hearing loss. See VA Medical Records Received December 2020. The Veteran underwent a VA examination in July 2011. The examiner noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 15 20 25 LEFT 15 15 15 20 25 Speech recognition scores were 94 percent bilaterally. These findings correlate to a designation of level I for the right ear, and level I for the left ear. Those results correspond to a non-compensable rating under DC 6100. May 2012 and February 2013 VA medical records note examinations of the ears which were negative for hearing loss. See VA Medical Records Received December 2020. The Veteran underwent another VA examination in May 2016. The examiner noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 25 25 20 LEFT 20 20 25 25 30 Speech recognition scores were 100 percent for the right ear and 96 percent for the left ear. These findings correlate to a designation of level I for the right ear, and level I for the left ear. Those results correspond to a non-compensable rating under DC 6100. November 2017, March, September and November 2018, and September 2019 VA medical records note examinations of the ears which were negative for hearing loss. See VA Medical Records Received December 2020. The Veteran underwent a VA examination in January 2020. The examiner noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 15 25 20 20 25 LEFT 20 20 15 20 30 Speech recognition scores were 100 percent bilaterally. These findings correlate to a designation of level I for the right ear, and level I for the left ear. Those results correspond to a non-compensable rating under DC 6100. The Veteran reported that his hearing loss affected communication with others. The examiner noted mild hearing difficulties with background noise. In some situations, the examiner noted the Veteran should corroborate words. However, in quiet environments, the examiner noted that the Veteran would confront minimal communication difficulties. He was found able to perform many tasks, except transcribing conversations. The Veteran last underwent a VA examination in November 2020. The examiner noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 20 50 60 60 60 LEFT 30 50 45 50 55 Speech recognition scores were 88 percent for the right ear and 86 percent for the left ear. These findings correlate to a designation of level II for the right ear, and level II for the left ear. Those results correspond to a non-compensable rating under DC 6100. With regard to the functional impact of the Veteran's hearing loss, the examiner noted that he reported his hearing was terrible and that he had to read people's lips. Lastly, a February 2021 VA medical record shows the Veteran denied having any hearing loss. After a review of the evidence of record, the Board finds that, throughout the period on appeal, a compensable rating for bilateral hearing loss is not warranted. The criteria for rating hearing impairment requires consideration of the results of examinations using controlled speech discrimination tests (Maryland CNC) with the results of puretone audiometry tests. The results are charted on Table VI and Table VII, as set forth in the Rating Schedule. In order to establish entitlement to a higher rating for hearing loss it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average puretone decibel loss are met. 38 C.F.R. § 4.85. Hearing tests will be conducted without hearing aids. The regulations set forth eleven auditory acuity levels, designated from Roman numerals I to XI, in escalating order of hearing impairment. 38 C.F.R. § 4.85. The appropriate auditory acuity level is determined based on a combination of the percentage of speech discrimination and the puretone threshold average. Additional considerations apply when exceptional patterns of hearing loss are demonstrated, which are defined as either a) puretone averages of 55 or greater at 1000, 2000, 3000, and 4000 Hertz, or; b) a puretone threshold of 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86(a). Once an acuity level is established for each ear, Table VII, Percentage Evaluations for Hearing Impairment, is used to determine the appropriate disability evaluation. The appropriate rating is determined based on a combination of the levels of hearing impairment established for each ear. The Board recognizes that the claims file includes numerous audiological evaluations. In this regard, several of these evaluations, particularly the private audiological evaluations, do not indicate that the Maryland CNC word list was utilized. Accordingly, those audiological evaluations are not adequate for rating purposes. However, even if the Board were to consider all audiological evaluations of record, throughout the period on appeal, the Veteran's bilateral hearing loss has been manifested by not worse than level II for the right ear, and level II for the left ear. Those results correspond to a noncompensable rating. The Board emphasizes that disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Therefore, at any time during the period on appeal, the currently assigned non-compensable evaluation accurately reflects the Veteran's disability picture as contemplated under the VA rating criteria. To the extent he may argue or suggest that the clinical data supports an increased disability rating or that the rating criteria should not be employed, he is not competent to make that assertion. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). As indicated, the rating of hearing loss disabilities requires the administration of audiometric testing that is administered and interpreted by a professional. The Board is cognizant that the January 2020 and November 2020 VA examinations indicated that the Veteran's hearing loss impacted his ability to work. In this regard, the January 2020 VA examiner noted that the Veteran reported his hearing loss affected his ability to communicate with others. The November 2020 VA examination noted the Veteran reported his hearing was terrible, and that he was required to read lips. However, a review of the Veteran's treatment records shortly before these examinations noted examination of the ears which were negative for hearing loss. Importantly, after his most recent November 2020 VA examination, in February 2021, a VA medical record shows the Veteran specifically denied having any hearing loss. The Board finds the February 2021 VA medical record particularly probative as it indicates that the review of systems was provided "per the Veteran." In this regard, the Board notes that statements made to clinicians for the purpose of treatment are considered reliable because one seeking medical treatment is aware of the necessity for being truthful to secure proper care. See Rucker v. Brown, 10 Vet. App. 67 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment). Accordingly, with regard to the effects of his hearing loss on his daily activities provided during the January and November 2020 VA examinations, the Board finds the Veteran to be an unreliable historian and provides such statements little probative value. Nevertheless, the Board finds that the Veteran's hearing loss likely has some effect on his ability to communicate with others. However, the evidence of record does not reflect an inability to communicate with minimal background noise or face to face conversation. Further, in Doucette v. Shulkin, 28 Vet. App. 366 (2017), the United States Court of Appeals for Veterans Claims held that the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment as these are the effects that VA's audiometric tests are designed to measure. The Veteran has not otherwise credibly described functional effects that are considered exceptional, or that are not otherwise contemplated by the assigned evaluation. Id. Thus, his complete disability picture is compensated under the rating schedule. Therefore, according to the valid audiometric examinations conducted during the period on appeal, the Board finds that an initial compensable rating is not warranted. Consequently, the preponderance of the evidence is against any increased rating during the period on appeal. The claim is denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3.-4. Dermatitis An April 2017 rating decision granted service connection for dermatitis and assigned an initial 10 percent rating effective September 6, 1993 (the day following separation from service), and a 60 percent rating effective August 30, 2002. The Veteran has appealed those ratings. See May 2017 NOD. Initially, the Board notes that the Veteran has separately been rated under 38 C.F.R. § 4.118, DC 7800 for scars of the face, effective September 6, 1993. That rating is not on appeal. Shortly prior to the period on appeal, the Veteran's July 1993 separation examination noted the right hand was hyperpigmented and a skin lesion was noted to be present between the right 2nd and 3rd digit the past 6 months. During the period on appeal, a June 1994 VA medical record shows the Veteran reported an intermittent itching rash on both arms. He was assessed with raised lesions over the lateral aspect of his left arm and diagnosed with eczematous dermatitis. In September 1994, erythema and papules were noted on the forearm, finger and legs. He was treated with oil and cream. A February 1995 VA medical record noted diagnoses for eczema and verruca plana. He was treated with creams and ointments. In September 1995, the Veteran was assessed with a dark pruritic rash below his elbows, and a small lesion on his chest. He was diagnosed with atopic dermatitis and treated with daily prednisone (corticosteroid) and another unreadable medication. Another September 1995 VA medical record shows the Veteran reported that his skin problems were worsening. He reported a rash and itching on his bilateral arm and groin. He was assessed with a skin rash and treated with a cream. See VA Medical Records Received March 2002. In November 1996, the Veteran complained of bumps on his forehead the past month, and bumps on his right arm and elbow for a much longer time. He was assessed with an urticaria type of rash. Another November 1996 VA medical record noted a papular rash over the right elbow and the right ankle which was pruritic. He was assessed with dermatitis and treated with Diprolene and antifungal creams. See VA Medical Records Received March 2002. The Veteran underwent a VA general examination in January 1997. Atopic dermatitis was noted in the groin area, ankles and "tennis skin" which was recurrent and exacerbated on occasion. He initially underwent a VA skin examination in January 1997. The examiner noted diagnoses for atopic eczema. The skin condition was noted as being treated with Diprolene with some itch improvement, but with a persistent rash. Erythematous scaly patches and papules were found on the lateral aspect of the bilateral elbow and leg. No lesions were found on the trunk. The Veteran complained of recurrent dermatitis on his bilateral arm and posterior part of this right lower extremity in January 1997. He reported his skin rash was aggravated in June 1997. A raised nodular rash and peeling skin were noted in the same areas, including the left arm and the back of the right leg. He was assessed with dermatitis and prescribed betamethasone cream. A December 1997 VA medical record shows the Veteran reported a rash on his arm and on the soles of his feet. The clinician noted red, raised bumps on the left forearm and the left ankle area below the sock line. He was assessed with recurrent dermatitis and prescribed a cream for treatment. See VA Medical Records Received May 1999. A November 2000 VA general examination noted healing residual skin lesions over the left forearm, with similar lesions on the opposite forearm with pigmentation changes. Lumpy residual lesions were also noted affecting the left thigh. The examiner noted an absence of deformities. Additionally, a January 2004 VA general medical examination shows the Veteran reported suffering from recurrent rashes that occurred on his hands, legs, ankles, forearms and face. The examiner noted the Veteran had been treated with different ointments and creams, including betamethasone with clotrimazole, among others. The skin condition was currently manifested by a raised lesion over the web space of his 4th and 5th fingers on the right hand, and residual slightly hyperpigmented skin from old healed papular lesions over the left forearm and arm. No other abnormal skin findings were noted. An August 2008 VA general examination noted skin symptoms of itching and rashes. Bilateral lower leg excoriation and patches of hyperpigmented, very dry and scaling skin were currently observed. A July 2009 private medical record shows the Veteran complained of a rash on his legs and he reported getting rashes all over. Current medications included nystatin and clobetasol. Dry skin was noted on the upper extremities, and macular hyperpigmentation was noted on the lower extremities. The Veteran was diagnosed with chronic dermatitis and post-inflammatory hyperpigmentation. See Private Medical Record Received February 2017. The Veteran underwent another VA skin examination in April 2012. Diagnoses for dermatomycosis and eczema were noted. The examiner noted the Veteran had not received any treatment including oral or topical medications in the past 12 months, although topical corticosteroids were noted as treatment medication. The skin condition was found to cover less than 5 percent of the Veteran's total body area, and less than 5 percent of his exposed area. During a May 2016 VA skin examination, the service-connected dermatitis was noted to have been treated with constant/near-constant oral cetirizine and topical hydrocortisone medications in the past 12 month period. Dermatitis was found to cover less than 5 percent of the Veteran's total body and exposed area. The dermatitis appeared as eczematous patches on the forearms, lower extremities, abdomen and back. An April 2017 VA skin examination noted diagnoses for dermatitis. The Veteran reported that he currently used daily topical creams prescribed by his VA dermatologist which had stabilized his condition. The examiner found that the skin condition did not cause scarring or disfigurement of the head, face or neck. Current treatments in the past 12 months included constant/near constant antihistamines, topical corticosteroids including betamethasone dipropionate, betamethasone valerate, desonide and triamcinolone. Other topical medications noted included doxepin cream for itching. A physical examination found that the service-connected dermatitis covered between 5 percent and less than 20 percent of the Veteran's total body area, and none of his exposed area. The examiner further noted that the dermatitis was currently manifested by a large patch of papules with some of them erythematous on the left forearm, diffuse papules on the right arm, and post-inflammatory hyperpigmented scaling on the back of the right lower leg. The Veteran last underwent a VA skin examination in January 2020. Diagnoses for dermatitis, dermatophytosis and episodes of cellulitis were noted. The Veteran reported persistent skin rashes and itching, mostly on his arms, legs, groin, gluteales and back. He also reported intermittent episodes of cellulitis on areas of his dermatitis, with the most recent episode in March 2019. The skin condition was noted as being treated in the past 12 months with constant/near constant topical corticosteroids or other immunosuppressive medications, including betamethasone valerate lotion, betamethasone dipropionate cream, desonide creams and ketoconazole shampoo. Other topical treatments included doxepin cream and pramoxine lotion. In addition, oral antihistamines were noted as used on a constant/near constant basis over the past 12 months. Dermatitis was found to cover between 5 percent to less than 20 percent of the total body area, and less than 5 percent of his exposed skin area. The examiner noted dermatitis characterized as diffuse hyperpigmented macules on the arms, hands and back, multiple dark brown macules on the legs, and some areas of scaliness on the arms and hands. The skin conditions were not found to cause scarring. The Veteran's skin condition, dermatitis, has been rated pursuant to 38 C.F.R. § 4.118, DC 7806. As DC 7806 specifically evaluates dermatitis, the Board notes that rating his service-connected dermatitis by analogy under another diagnostic code would not be appropriate. Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). The Board further notes that during the period on appeal, the rating criteria related to skin conditions have undergone two amendments: the first effective August 30, 2002, and the second effective August 13, 2018. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Under the regulations in effect prior to August 30, 2002, DC 7806 (eczema) provided a 10 percent evaluation for exfoliation, exudation, or itching, if on an exposed surface or extensive area. A 30 percent evaluation was provided for exudation or itching constant, extensive lesions, or marked disfigurement. A 50 percent evaluation was provided for ulceration or extensive exfoliation or crusting, and system or nervous manifestations, or exceptionally repugnant. 38 C.F.R. § 4.118, DC 7806 (prior to August 30, 2002). Beginning August 30, 2002, a 10 percent evaluation under DC 7806 (now characterized as dermatitis or eczema) was assigned when the condition covered at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of exposed areas affected, or; when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation was warranted if the skin condition covered 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; when systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation was warranted if the skin condition covered more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, DC 7806 (August 30, 2002 to August 12, 2018). Lastly, the amendment effective August 13, 2018, in pertinent part, added a "General Rating Formula for the Skin" for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824, and amended DCs 7801,7802,7817,7819,7825, 7826, 7827,7829. See 83 Fed. Reg. 32,592 (July 13, 2018). Under the General Rating Formula for the Skin, pursuant to DCs 7806, 7809, 7813-7816, 7820-7822, and 7824, a 10 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks or more, but not constantly, over the past 12-month period. 38 C.F.R. § 4.118, DC 7806 (2018). Also, under the General Rating Formula for the Skin, the rating criteria notes that for the purposes of that section, systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. Prior To August 30, 2002 Initially, pursuant to the rating criteria in effect prior to August 30, 2002, the Board notes that the Veteran's service-connected dermatitis was not manifested by the following: leishmaniasis, americana; leishmaniasis, old world; discoid lupus erythematosus; pinta; tuberculosis luposa; verruga peruana; dermatophytosis; tinea barbae; pemphigus; psoriasis; dermatitis exfoliativa; or, new malignant skin growths. Accordingly, prior to August 30, 2002, diagnostic codes 7807-7818 are not for application. Additionally, diagnostic codes 7807-7818, and 7819 (benign skin new growths) direct the rater to rate for eczema, dependent upon location, extent and repugnant or otherwise disabling character of manifestations. Therefore, the rating criteria are the same. Turning to DC 7806, after a full review of the record in conjunction with the applicable laws and regulations in effect throughout the period on appeal, the Board finds that an initial rating in excess of 10 percent is not warranted. In this regard, throughout the period on appeal, the Veteran's service-connected dermatitis was not manifested by constant exudation or itching, or extensive lesions, ulceration, crusting, system or nervous manifestations, or been found exceptionally repugnant. Instead, the medical records documents recurrent, and not constant, attacks of atopic dermatitis. See January 1997 VA Examination, and January 1997, December 1997, April 1999 VA Medical Records. The Board further notes that the evidence of record does not show that the dermatitis resulted in marked disfigurement. Instead, the medical evidence of record consistently shows intermittent manifestations with periods of exacerbations. Additionally, a November 2000 VA examination specifically indicated no deformities. The Board further finds it instructive that during this period on appeal, the Veteran has not asserted that his service-connected dermatitis resulted in any disfigurement. Accordingly, pursuant to the rating criteria in effect prior to August 30, 2002, the Board finds that a rating in excess of 10 percent under DC 7806 is not warranted. Effective August 30, 2002 After a review of the evidence of record, the Board finds that, effective August 30, 2002, a rating in excess of 60 percent disabling is not warranted. In this regard, throughout this period on appeal, the Veteran has been in receipt of the highest rating available for his service-connected dermatitis under DC 7806. The Veteran has not been diagnosed with exfoliative dermatitis (erythroderma). Thus, a higher rating under DC 7817 is not warranted. Moreover, under DC 7817, to warrant a 100 percent rating, generalized involvement of the skin, plus systemic manifestations (such as fever, weight loss, and hypoproteinemia, and: constant or near-constant systemic therapy required during the past 12 month period has not been shown. There is no indication that his skin condition results in fever, weight loss, and hypoproteinemia. Importantly, the Veteran has not asserted that there are identifiable symptoms that are outside the rating provisions. In sum, prior to August 30, 2002, the preponderance of the evidence of record is against a rating in excess of 10 percent disabling. Effective August 30, 2002, the preponderance of the evidence of record is against rating in excess of 60 percent disabling. The claims are denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.118; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5.-6. Bronchitis A June 1994 rating decision granted entitlement to service connection for bronchitis and assigned an initial 10 percent rating. A March 2002 rating decision further continued that rating. The Veteran has appealed those rating decisions. During the period on appeal, the Veteran initially underwent a VA respiratory examination in February 1997. He complained of breathlessness following physical efforts. The examiner noted two normal chest X-rays in the past year and that the Veteran was not using any medications to treat his bronchitis. No evidence of cor pulmonale was found. Mild dyspnea was noted upon moderate efforts. A PFT revealed pre-bronchodilator results of FEV-1 of 93 percent predicted. No post-bronchodilator, FEV-1 or DLCO results were recorded. The examiner concluded that no significant pulmonary abnormality was found. The Veteran underwent another VA respiratory examination in October 2000. The examiner noted a history of chronic bronchitis and cigarette smoking. The Veteran reported shortness of breath on moderate efforts. He also asserted having recurrent bronchitis episodes that were treated with antibiotics. Dyspnea was reported on exertion upon climbing 1 to 2 flights of stairs. The examiner noted treatment with an Albuterol inhaler. No wheezes, rales or rhonchi were found. The examiner also noted no history of cor pulmonale. A PFT revealed pre-bronchodilator result of FEV-1 of 88 percent predicted, and DLCO of 89 percent predicted. FEV-1/FEC results were not included. Additionally, the PFT did not include post-bronchodilator results. An August 2008 VA general examination noted a PFT revealing moderate obstructive and mild restrictive ventilatory impairment with decreased airway resistance. The Veteran reported frequent dyspnea and shortness of breath 5 to 6 times per month with certain efforts like climbing a flight of stairs, lifting or carrying heavy objects, and prolonged walking. Oxygen saturation by pulse oximeter was 99 percent. A December 2008 VA respiratory examination noted a diagnosis for bronchitis and a history of asthma. The Veteran reported a worsening condition with symptoms of a persistent cough, shortness of breath and chest tightness with recurrent asthma attacks. The examiner noted treatment with daily inhaled bronchodilator and inhaled anti-inflammatory medication. A PFT revealed post-bronchodilator results of FEV-1 of 71 percent predicted, and FEV-1/FVC of 99 percent predicted. The Veteran underwent another VA respiratory examination in August 2011. The examiner noted diagnoses for bronchitis. The Veteran reported that his condition had worsened in the past 3 years, requiring multiple emergency room visits. The examiner noted treatment with daily inhaled bronchodilator and daily inhaled anti-inflammatory medications. A PFT revealed post-bronchodilator results of FEV-1 of 82 percent predicted, and FEV-1/FVC of 103 percent predicted. Additionally, a March 2012 VA respiratory examination noted the same August 2011 PFT results. The Veteran reported that he retired in 1993 due to medical problems, including chronic fatigue, bronchitis, headaches and joint pain. During a May 2016 VA respiratory examination, the examiner noted a diagnosis for chronic bronchitis. The respiratory condition was noted as being treated with inhalation bronchodilator therapy, and inhalation anti-inflammatory medication. Oral bronchodilators, antibiotics and outpatient oxygen therapy were not used as current treatments. Asthma was also noted as a pulmonary condition, but no episodes were reported within the past 12 months. A PFT revealed post-bronchodilator results including FEV-1 of 73 percent predicted, and FEV-1/FVC of 103 percent predicted. The examiner noted that FEV-1 testing most accurately reflected the Veteran's level of disability. The examiner noted that the Veteran should avoid triggers for his asthma exacerbations in order for his respiratory condition not to impact his ability to work. A February 2021 VA medical record noted no new or worsening coughs or shortness of breath. See February 2021 VA Medical Records Received February 2021. Lastly, in a March 2021 Advisory Opinion, the Executive Director, Compensation Service, determined that the available medical evidence did not support a higher evaluation for the service-connected bronchitis on an extra-schedular basis. In support of this determination, the Director noted that the condition had not been manifested by any demonstrated unusual or exceptional disability pattern that would render application of the regular rating criteria impractical. After a review of the evidence of record, the Board finds that, prior to June 18, 2002, a rating in excess of 10 percent is not warranted. The Board further finds that effective June 18, 2002, a rating in excess of 30 percent is not warranted. The Veteran's bronchitis is rated pursuant to C.F.R. § 4.97, DC 6600. Under DC 6600, a 10 percent disability rating is warranted for FEV-1 of 71 to 80 percent predicted, or FEV-1/FVC of 71 to 80 percent predicted, or, DLCO (SB) of 66 to 80 percent predicted. A 30 percent rating is warranted for FEV-1 of 56 to 70 percent predicted, or FEV-1/FVC of 56 to 70 percent predicted, or, DLCO (SB) of 56 to 65 percent predicted. A 60 percent disability rating is warranted for FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg in (with cardiorespiratory limit). A maximum schedular 100 percent disability rating is warranted for FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg in oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. 38 C.F.R. § 4.97, DC 6600. The Board notes that there are special provisions for the application of the rating criteria for certain diagnostic codes, including DC 6600, 6603, 6604, 6825-6833, and 6840-6845. 38 C.F.R. § 4.96(d). PFTs are required to evaluate these conditions, except when the results of maximum exercise capacity test are of record and are 20 ml/kg or less; when pulmonary hypertension cor pulmonale or right ventricular hypertrophy has been diagnosed; when there have been one or more episodes of acute respiratory failure; or when outpatient oxygen therapy is required. 38 C.F.R. § 4.96(d)(1). If DLCO (SB) results are not of record, such conditions are evaluated based on alternative criteria as long as the examiner states why the test would not be useful or valid in a particular case. 38 C.F.R. § 4.96(d)(2). When PFTs are not consistent with clinical findings, conditions are evaluated based on the PFTs unless the examiner states why they are not a valid indication or respiratory functional impairment in a particular case. 38 C.F.R. § 4.96(d)(3). Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when the results of pre-bronchodilator pulmonary function tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. 38 C.F.R. § 4.96(d)(4). When evaluating based on PFTs, post-bronchodilator results are to be used unless the post-bronchodilator results were poorer than the pre-bronchodilator results, in which case, the pre-bronchodilator results are used for rating purposes. 38 C.F.R. § 4.96(d)(5). When there is a disparity between the results of different PFTs, so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96(d)(6). Turning to the period on appeal prior to June 18, 2002, the Board finds that a rating in excess of 10 percent is not warranted. In this regard, PFT data does not show that the Veteran's bronchitis was manifested by FEV-1 less than 71 percent predicted, or DLCO less than 66 percent predicted. The Board recognizes that PFT results during this period on appeal did not include post-bronchodilator results, or FEV1/FVC data. Regulation 38 C.R.F. § 4.96(d)(4) notes that when evaluating based on PFTs, use post-bronchodilator results in applying the evaluation criteria in the rating schedule unless the post-bronchodilator results were poorer than the pre-bronchodilator results. In those cases, use the pre-bronchodilator values for rating purposes. In this regard, the Board notes that post-bronchodilator testing is administered after administration of medication that opens the bronchial tubes. Accordingly, even in consideration of PFT results prior to administration of medication, the values do not more nearly approximate FEV-1 of 56 to 70 percent predicted, or DLCO of 56 to 65 percent predicted. The Board additionally finds it instructive that the February 1997 VA examiner concluded that there were no significant pulmonary abnormalities at the time of the examination, and the October 2000 VA examiner noted no wheezes, rales or rhonci during the examination. Turning to the period on appeal effective June 18, 2002, the Board finds that a rating in excess of 30 percent is not warranted. In this regard, during this period on appeal, PFT results do not show post-bronchodilator results of FEV-1 or FEV-1/FVC less than 56 percent predicted, the criteria for a higher 60 percent evaluation. In fact, PFT data during this period on appeal does not show FEV-1 or FEV-1/FVC less than 71 percent predicted, the criteria for a 30 percent evaluation. Instead, a review of the June 2009 rating decision shows that the 30 percent evaluation was not based on PFT data, but the August 2008 VA general examination which noted a PFT, but not the results. The cited PFT was noted to reveal moderate obstructive and mild restrictive ventilatory impairment. In consideration that a PFT conducted less than 4 months later showed postbronchodilator results of FEV-1 of 71 percent predicted, and FEV-1/FVC of 99 percent predicted, the Board concludes that at no point during the period on appeal has the Veteran's bronchitis more nearly approximated a higher 60 percent rating. The Board has also considered extraschedular consideration. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate. Thun v. Peake, 22 Vet. App. 111 (2008). As noted above, this claim was referred to the Director Compensation Service for consideration of an extraschedular rating. However, the Director concluded that no unusual or exceptional disability pattern had been demonstrated and that the evidence did not support an extraschedular rating. The Board agrees. In this regard, the evidence of record does not show that the Veteran undergoes frequent hospitalizations related to his bronchitis. The Board does recognize that during the August 2011 VA examination, the Veteran reported that he retired in 1993 due to medical problems, including chronic fatigue, bronchitis, headaches and joint pain. However, the evidence of record does not show that the severity of the service-connected bronchitis is such that it would result in marked interference with employment. In this regard, the Board finds it instructive that the Veteran has been granted entitlement to a TDIU, but not due to, or in part by, his service-connected bronchitis. Instead, the Veteran was granted entitlement to a TDIU based solely on his service-connected psychiatric disorder. Moreover, the rating criteria provides higher ratings for more severe symptomatology related to his bronchitis, which has not been shown by the record. Accordingly, the Board finds that the rating criteria adequately contemplates the symptoms related to the Veteran's service-connected bronchitis. As such, the Board finds that an extraschedular rating is not warranted. In consideration of the above, the Board concludes that prior to June 18, 2002, the preponderance of the evidence is against an initial rating in excess of 10 percent disabling. Effective June 18, 2002, the Board finds that the preponderance of the evidence is against a rating in excess of 30 percent disabling. The claims are denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.97, DC 6604; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 7. Diabetes The Veteran seeks entitlement to service connection for diabetes. Specifically, the Veteran asserts that his diabetes is directly related to environmental exposure during service. Alternatively, he asserts that his diabetes is secondary to his service-connected posttraumatic stress disorder (PTSD), chronic fatigue syndrome (CFS) and gastroesophageal reflux disease (GERD). See February 2017 Claim, June 2017 NOD, and June/July 2018 Letters. The claims file includes a number of VA examination reports. The Veteran initially underwent a VA diabetes examination in March 2017. The examiner opined that the diabetes was less likely as not (less than 50/50 probability) proximately due to or the result of CFS. In support of this opinion, the examiner noted a review of the claims file, medical literature and an interview with the Veteran. The examiner noted that type II diabetes patients become resistant to the action of insulin, and the pancreas becomes unable to make enough insulin to overcome that resistance. Instead of moving into the cells where insulin is needed for energy, sugar instead builds up in the bloodstream. The examiner noted that it was believed that genetic and environmental factors played a role in the development of the condition. In addition, being overweight was also noted as being strongly linked to the development of type II diabetes. With regard to direct service connection, the examiner noted that the STRs were silent regarding any symptoms or diagnosis of the condition, and that there was no evidence of any manifestation or diagnosis of diabetes within a year after separation from service. As the examiner did not provide a medical opinion as to whether the Veteran's diabetes was caused or aggravated by a service-connected disability, the claim was remanded in October 2018. In a February 2019 VA addendum examination report, the examiner opined that it was "less likely than not (less than 50% probability)" that the diabetes was proximately due to or the result of the Veteran's service-connected conditions. In support of this opinion, the examiner noted that medical literature established that genetic and environmental factors, as well as family history and geography, played a role in the development of type II diabetes. The examiner further noted that medical literature had not established that CFS, PTSD or GERD caused or aggravated diabetes. The Board found the February 2019 addendum inadequate as the examiner did not cite to any particular medical literature that supported the statements provided. Accordingly, the Board found the opinion was not fully explained and that the Veteran's assertions were not fully addressed. The matter was therefore remanded to obtain another VA examination. In a December 2020 VA addendum medical opinion, the examiner opined that it was "less likely than not (less than 50% probability)" that the Veteran's diabetes was proximately due to or the result of his service-connected disabilities. In support of this opinion, the examiner noted that the medical literature did not establish that diabetes could be caused by his service-connected disabilities, including CFS, PTSD and/or GERD. Instead, the examiner noted that the medical literature established that genetic and environmental factors played a role in the development of type II diabetes. In addition, being overweight was also noted as being strongly linked to the development of type II diabetes. Other known risk factors cited included family history and geography. The examiner further opined that there was no objective evidence that the Veteran's diabetes was "aggravated beyond the natural progress by his service-connected disabilities." In support of this opinion, the examiner again noted that the medical literature did not support a finding that the service-connected disabilities, including CFS, PTSD and/or GERD, could aggravate diabetes. Instead, the only condition noted that could cause the Veteran's body mass index to increase was his GERD. In addition, the examiner stated that "[w]e know that many people with diabetes mellitus are overweight, so it seems to make sense that GERD is more common in these individuals." The Board finds the December 2020 VA examination inadequate. First, although the examiner noted risk factors including environment and geography, the examiner never addressed the Veteran's assertion that his diabetes was caused by environmental exposure during his deployment to Southwest Asia, during which he reported exposure to "many unknown harmful elements and agents and placed in many health endangering environments..." See June 2018 Letter. Second, the examiner appears to assert that the Veteran's service-connected GERD might have caused his body mass index to increase. The examiner further correlated being overweight with developing diabetes. In this regard, the record shows the Veteran has asserted that his service-connected disabilities had negatively affected his activities of daily living. See June 2018 Letter and March 2019 Statement in Support of Claim. Accordingly, the Board finds that the record has raised the issue of obesity as an intermittent step between the Veteran's service-connected disabilities and his diabetes. In this regard, a review of the VA medical records shows that obesity has been cited as a medical condition. See February 2019 VA Medical Record. Lastly, the Board notes that a May 2021 brief, the representative submitted a piece of medical literature titled, "Diabetes, Psychiatric Disorders, and the Metabolic Effects of Antipsychotic Medications." The medical literature notes that psychiatric disorders could be a risk factor for, as well as a complication of, diabetes, and that antipsychotic medications were also associated with diabetes. As the submitted medical literature has not been considered by any VA examiner, any subsequent VA examination report should consider it in rendering a medical opinion. Accordingly, in order to adequately adjudicate this issue on appeal, a Remand is necessary to obtain a VA examination that addressed the above issue. The matter is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of his diagnosed diabetes (or telehealth interview, review of the record, etc., if an in-person examination is not feasible or necessary). The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed diabetes is etiologically related to his period of service? The examiner is asked to consider the Veteran's lay statements that he developed diabetes due to environmental exposure during his deployment to the Southwest Asia Theatre of Operations. (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed diabetes was caused by his service-connected disabilities? Please explain why or why not. The examiner is asked to consider the Veteran's lay statements that his service-connected disabilities affected his over-all health and process of nutrition, including his GERD, PTSD and CFS. The examiner is also asked to consider the Veteran's submitted medical journal article. See treatise by Maria D. Llorente, MD and Victoria Urrutia, MD, "Diabetes, Psychiatric Disorders, and the Metabolic Effects of Antipsychotic Medications" (January 2006) (https://clinical.diabetesjournals.org/content/24/1/18). (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed diabetes was aggravated by his service-connected disabilities, to include PTSD, CFS and GERD? Please explain why or why not. If the examiner finds that the disability was aggravated by the service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. The examiner is asked to consider the Veteran's lay statements that his service-connected disabilities affected his over-all health and process of nutrition, including his GERD, PTSD and CFS. The examiner is also asked to consider the Veteran's submitted medical journal article. See treatise by Maria D. Llorente, MD and Victoria Urrutia, MD, "Diabetes, Psychiatric Disorders, and the Metabolic Effects of Antipsychotic Medications" (January 2006) (https://clinical.diabetesjournals.org/content/24/1/18). The examiner is also asked to determine the nature and likely etiology of the Veteran's obesity and (claimed disability). Based on claims file review and examination of the Veteran, the examiner should provide opinions responding to the following: (a) Opine as to whether it is at least as likely as not (50% or better probability) that service-connected disabilities, to include anxiety disorder, CFS, bronchitis, lumbar spine disability and GERD, caused the Veteran to become obese, to include as due to any lack of exercise resulting from his service-connected disabilities. (b) If the answer to (a) is "no," opine as to whether it is at least as likely as not (50% or better probability) that the Veteran's service-connected disabilities, to include anxiety disorder, CFS, bronchitis, lumbar spine disability and GERD, aggravated his obesity, to include as due to any lack of exercise resulting from service-connected disability. (c) Opine as to whether it is at least as likely as not (50% or better probability) that obesity (or the aggravation of obesity per question (b)) was a substantial factor in causing the Veteran's diabetes. (d) Opine as to whether it is at least as likely as not (50% or better probability) that the Veteran would not have diabetes if he were not obese (or but for obesity aggravated by his service-connected disabilities per question (b)). The examiner should review pertinent documents in the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Lamb, 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.