Citation Nr: 21044090 Decision Date: 07/20/21 Archive Date: 07/20/21 DOCKET NO. 09-22 958 DATE: July 20, 2021 ORDER Service connection for arthritis of the right hip, as secondary to service-connected posttraumatic stress disorder (PTSD) with secondary binge eating disorder, is granted. Service connection for degenerative arthritis of the right and left shoulders, as secondary to service-connected PTSD with secondary binge eating disorder, is granted. An initial rating of 50 percent for tension headaches is granted. REMANDED The issue of entitlement to service connection for breathing problems, diagnosed as asthma, is remanded. The issue of entitlement to an initial rating greater than 10 percent for degenerative arthritis of the right knee is remanded. The issue of entitlement to a higher initial rating for cervical strain and degenerative arthritis of the spine, evaluated as 10 percent disabling prior to December 1, 2016, and at 20 percent disabling thereafter, is remanded. The issue of entitlement to a higher initial rating for PTSD, evaluated as 30 percent disabling prior to September 7, 2010, and as 70 percent disabling from September 7, 2010, to March 15, 2013, is remanded. The issue of entitlement to an effective date prior to October 12, 2010, for the establishment of basic eligibility for Dependents Educational Assistance (DEA) benefits under Chapter 35, Title 38, United States Code, is remanded. FINDINGS OF FACT 1. The Veteran currently has arthritis of the right hip, and competent medical opinion evidence indicates that the Veteran's right hip degenerative arthritis is due, at least in part, to post-service weight gain/obesity that has been attributed to her service-connected PTSD with secondary binge eating disorder. 2. The Veteran currently has degenerative arthritis of the right and left shoulders, and competent medical opinion evidence indicates that the Veteran's right and left shoulder arthritis is due, at least in part, to post-service weight gain/obesity that has been attributed to her service-connected PTSD with secondary binge eating disorder. 3. Since the June 21, 2013, effective date of service connection, the Veteran's tension headaches included very frequent completely prostrating with prolonged attacks capable of producing severe economic inadaptability. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for degenerative arthritis of the right hip, as secondary to service-connected PTSD with secondary binge eating disorder, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for degenerative arthritis, bilateral shoulders, as secondary to service-connected PTSD with secondary binge eating disorder, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. Resolving all reasonable doubt in the Veteran's favor, the criteria for an initial disability rating of 50 percent for tension headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.3, 4.10, 4.124a, Diagnostic Code (DC) 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty service in the United Stated Air Force from February 1975 to July 1980. This appeal to the Board of Veterans' Appeals (Board) arose from June 2007, February 2012, April 2012, August 2013, and December 2014 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2016, the Veteran testified during a Board video-conference hearing before a Veterans Law Judge (VLJ); a hearing transcript has been associated with the claims file. In March 2021, the Veteran and her representative were notified that the VLJ who conducted the December 2016 hearing was no longer employed at the Board. The Veteran was informed that she could request another hearing before a different VLJ and was notified that if she did not respond within 30 days from the date of that letter that the Board would assume she did not desire another hearing and would proceed accordingly. No response was received from the Veteran within the allotted time period. Thus, the Board will assume she does not desire an additional hearing. The procedural history of this case is a lengthy one that involves multiple actions by the Board and several appeals to and remands from the United Stated Court of Appeals for Veterans Claims (Court). As the procedural history has been detailed at length in the prior actions in the appeal, it will only be repeated herein as needed to explain the state of the matters currently before the Board. Most recently, in an April 2019 decision, the Board granted service connection for breathing problems, diagnosed as restrictive disease, but denied breathing problems due to asbestosis. The Board also remanded, for further development, the issue of entitlement to service connection for breathing problems, diagnosed as asthma. Also remanded by the Board were the issues of entitlement to service connection for joint pain and arthritis (involving the right hip and bilateral shoulders), entitlement to higher initial ratings for cervical strain and degenerative arthritis of the spine, evaluated as 10 percent disabling prior to December 1, 2016, and as 20 precent disabling thereafter, and for degenerative arthritis of the knee, evaluated as 10 percent disabling. The issue of entitlement to an effective date prior to October 12, 2010, for the establishment of basic eligibility for DEA benefits was also remanded, as it was found to be inextricably intertwined with the other remanded issues. Additionally, the Board denied entitlement to higher initial ratings for service-connected tension headaches and PTSD, as well as entitlement to SMC based on the need for aid and attendance of another person. Thereafter, the Veteran filed an appeal to the Court and in October 2019, the Court granted a Joint Motion for Partial Remand (Joint Motion) filed by the Veteran's then-representative and VA's General Counsel and vacated the Board's April 2019 decision insofar as it had denied entitlement to higher initial ratings for tension headaches and PTSD; those matters were then returned to the Board for readjudication consistent with the terms of the parties' Joint Motion. Notably, the Veteran did not challenge the Board's April 2019 decision insofar as it had denied service connection for breathing problems due to asbestosis and/or entitlement to SMC. As such, those issues are no longer on appeal. Regarding the issues remanded in the April 2019 action, the record shows that on remand, the Veteran was afforded various VA examinations in December 2019. The agency of original jurisdiction (AOJ) then issued a supplemental statement of the case (SSOC) in August 2020 in which it continued to deny service connection for breathing problems, diagnosed as asthma, and for joint pain and arthritis (involving the right hip and shoulders), higher initial ratings for cervical strain and degenerative arthritis of the spine and for degenerative arthritis of the right knee, and an earlier effective date for the establishment of basic eligibility for DEA benefits. Those matters were returned to the Board the following month for further appellate consideration. Regarding the claim for service connection for breathing problems, the Board notes that in an April 2021 Informal Hearing Presentation (IHP), the Veteran's representative framed the issue as "[e]ntitlement to service connection for a breathing condition, to include asthma and sleep apnea." Although the Court has held that the scope of a service connection claim includes any diagnosed disability that may reasonably be encompassed by the claimant's description of the claim, the reported symptoms, and the other information of record, see Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board cannot at this juncture consider sleep apnea to be part of the Veteran's pending claim for service connection for breathing problems. This is so because entitlement to service connection for sleep apnea was previously on appeal to the Board. However, that claim was withdrawn during the Veteran's 2016 hearing and the appeal as to such was subsequently dismissed in a 2017 Board decision. Thus, because the claim was previously and finally denied, service connection for sleep apnea may now be considered on the merits only if new and relevant evidence is submitted. Additionally, as to the Veteran's claim for service connection for joint pain and arthritis, previously characterized as involving the right hip and bilateral shoulders associated with obesity caused by service connected PTSD with binge eating disorder, as will be discussed in further detail below, because the evidence supports the grant of service connection for arthritis of the right hip, as well as for that of the bilateral shoulders, the Board has recharacterized that claim as involving two issues, with the right hip and bilateral shoulders being separate disabilities. Lastly, the Board notes that the Veteran was awarded a total disability rating based on individual unemployability (TDIU) due to her service-connected PTSD via rating decision dated in April 2012. An effective date of October 12, 2010, was eventually assigned via rating decision dated in April 2013. The Veteran then appealed the issue of entitlement to an effective date prior to October 12, 2010, for the award of a TDIU to the Board and in a June 2017 decision, the Board found that the criteria for withdrawal of the appeal as to the issue had been met. The appeal was therefore dismissed. In the April 2019 action, the Board noted that the Veteran's representative had argued that the issue of entitlement to a total disability rating based on individual unemployability was reasonably raised by the record for the period prior to October 12, 2010. The Board noted, however, that the Veteran and her representative requested to withdraw the appeal as to the issue of entitlement to an effective date prior to October 12, 2010, during the December 2016 Board hearing. The Board noted that the appeal as to that issue had been dismissed, and determined that because the Veteran had not challenged the Board's dismissal as to that issue when she appealed the June 2017 Board decision to the Court, the June 2017 Board decision became final. The Board determined, therefore, that the issue of entitlement to a TDIU for the period prior to October 12, 2010, was no longer before the Board. The Board notes that in a February 2021 Informal Hearing Presentation, the Veteran's representative has continued to maintain that the issue of entitlement to an effective date earlier than October 12, 2010, is properly before the Board, arguing the Veteran had not made a valid withdrawal of the appeal. As discussed in the prior actions in this appeal, however, because the Veteran did not challenge the Board's dismissal of the appeal as to the issue of entitlement to an effective date earlier than October 12, 2010, for the award of a TDIU, the Board's decision in that regard is final, and the issue is no longer before the Board. If the Veteran or her representative believes the Board's dismissal was improper, the Veteran or her representative may file a motion for revision of the June 2017 Board decision on the basis of clear and unmistakable error (CUE). Service Connection Service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.306. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection also may be established, on a secondary basis ,by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). At the outset, the Board finds that the medical evidence of record demonstrates that the Veteran has current diagnoses of right hip bursitis, arthritis and trochanteric pain syndrome. The record also shows diagnoses of bilateral shoulder impingement syndrome and bilateral acromioclavicular joint osteoarthritis, as well as degenerative arthritis of both shoulders. Regarding the Veteran's claim for service connection for joint pain and arthritis involving the right hip and bilateral shoulders, the Veteran has stated her belief that her claimed joint pain and arthritis is associated with obesity caused by service connected PTSD with binge eating disorder. In this regard, the Board points out that the Veteran has been granted service connection for disabilities of the left hip and knee due to obesity resulting from her service-connected PTSD with secondary binge eating disorder. Pursuant to the terms of the Board's April 2019 remand, the AOJ afforded the Veteran a VA examination and obtained an addendum medical opinion in December 2019 regarding the likelihood that the Veteran has a right hip disability that is related to service or a service-connected disability. The VA examiner noted that the Veteran's left hip was higher than the right and that the Veteran had a slight narrowing or the right hip joint in the superior direction, consistent with degenerative arthritis of the right hip. The examiner then found that the Veteran has multiple contributing factors, to include "[a]dvancing age, diabetes, [and] obesity resulting in the right hip arthritis," stating that "studies show that these above factors result in right hip arthritis." Despite this statement, the examiner opined that the Veteran's right hip arthritis was not proximately due to or the result of the Veteran's PTSD with secondary binge eating disorder. Notably, the examiner did not consider whether the Veteran's obesity, noted to be a contributing factor for the development of arthritis, was due to her service-connected PTSD with secondary binge eating disorder. The Veteran was also afforded a VA shoulders examination in December 2019. A review of the examination and opinion reports shows that the examiner opined against an association between the Veteran's right and left shoulder disabilities and service or a service-connected disability. Notably, the negative nexus opinions contained flawed and confusing statements, to include that "[t]here is no objective evidence and definitive . . . left shoulder, or right shoulder disability and diagnosis," and limited or zero supporting rationale. Thus, the Board cannot conclude that the negative opinions are adequate to rely upon to deny service connection for the Veteran's claimed joint pain and arthritis involving the shoulders. However, rather than again remand the matter to obtain new medical opinions, the Board will simply resolve reasonable doubt in favor of the Veteran' s and award service connection for degenerative arthritis of the right and left shoulders. This is so because the VA examiner does state that the Veteran has multiple contributing factors for the development of right and left shoulder degenerative arthritis, to include obesity. As noted above, the Veteran is service connected for several disabilities of the left hip, secondary to her service-connected PTSD with secondary binge eating disorder. Notably, in awarding service connection for the left hip disabilities, the AOJ, in an August 2018 rating decision, conceded that the Veteran's obesity was due to her service-connected binge eating disorder. As such, that fact is not in dispute. The Board again points out that the December 2019 VA examiner affirmed that the Veteran's obesity, in part, led to the development of her right hip and bilateral shoulder arthritis. Notably, although obesity itself is not considered a disease or injury for which direct or secondary service connection may be granted, obesity can act as an "intermediate step" to establish service connection for another disability as secondary to an already service-connected disability under certain circumstances. See Marcelino v. Shulkin, 29 Vet. App. 155 (2018); VAOPGCPREC 1-2017. Specifically, VA's General Counsel has held that where it is shown that a service-connected disability causes a veteran to become obese and that obesity, in turn, is a substantial factor in causing additional disability, which disability, but for the veteran's obesity, would not have occurred, the resulting additional disability can be service-connected on a secondary basis. VAOPGCPREC 1-2017. In the instant case, the Veteran's obesity has been linked to her service-connected PTSD with secondary binge eating disorder. Additionally, the December 2019 VA examiner opined that the Veteran's obesity contributed to the Veteran's development of right hip arthritis, and affirmatively stated that obesity is a contributing factor in the development of right and left shoulder arthritis. Accordingly, given the totality of the evidence in this case, to include the competent medical evidence discussed above, and with resolution of all reasonable doubt on certain elements of the claim in the Veteran's favor, the Board finds that service connection for arthritis of the right hip and bilateral shoulders is warranted on a secondary basis. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see Gilbert, supra. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Generally, where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is entitlement to a higher initial rating following a grant of service connection, evaluation of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran asserts that her service-connected tension headaches have been more disabling that initially evaluated. Specifically, she asserts that her headaches should be evaluated as 50 percent disabling. At the outset, the Board notes that the Veteran's tension headaches have been evaluated as 30 percent disabling since June 21, 2013, under 38 C.F.R. § DC 8100. In this regard, the Board notes that headache disorders are often rated under 38 C.F.R. § 4.124a , DC 8100, pertaining to migraine headaches, regardless of whether there is a diagnosis of migraine headaches. This is so because unlisted conditions are to be evaluated under the criteria applicable to a closely related disease in which not only the functions affected, but the anatomical localization and symptomatology are closely related. 38 C.F.R. § 4.20. Here, the Board finds that the Veteran's symptoms are best reflected and contemplated by the criteria under DC 8100, which specifically provides for disability ratings for migraine headaches, to include economic inadaptability. As the Veteran has not reported symptoms not contemplated in the current rating criteria, the Board finds that a rating under another DC is not warranted. Under DC 8100, a noncompensable rating is assigned for migraines with less frequent attacks; a 10 percent rating is assigned for migraines with characteristic prostrating attacks averaging one in 2 months over last several months; a 30 percent rating is assigned for migraines with characteristic prostrating attacks occurring on an average once a month over last several months; and, a 50 percent rating is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. Thus, under DC 8100, both the frequency and the intensity of the headaches are relevant to determining the proper evaluation. 38 C.F.R. § 4.124a, DC 8100; see Johnson v. Wilkie, 30 Vet. App. 245, 253 (2018) (holding that the evaluation criteria under DC 8100 are successive). Evidence relevant to the issue of whether the Veteran's tension headaches are more severe than currently rated includes a VA treatment record dated in December 2013 wherein in it is noted that the Veteran had occasional headaches with neck pain. The Veteran was afforded a VA examination in September 2014 at which time she reported of 10 headaches per week, triggered by neck pain. The Veteran stated that she took over the counter medication for her headaches. It was noted that the Veteran experienced occiput and neck area headache pain and that she did not experience non-headache symptoms associated with headaches. The duration of headaches was less than one day. The location of the typical head pain was the occiput and neck area. The examiner concluded that the Veteran did not have characteristic prostrating attacks of migraine headache pain or very frequent prostrating and prolonged attacks of migraine headache pain. The examiner also concluded that the Veteran did not have prostrating attacks of non-migraine headache pain or frequent prostrating and prolonged attacks of non-migraine headache pain. In December 2014, the Veteran reported having headaches more frequently. VA treatment records then show that the Veteran reported having occasional headaches and in February 2015, the Veteran reported morning headaches. In February 2016, the Veteran reported daily headaches that could be triggered by bright light and loud noise. Her headache pain was reported to be a 9 on a scale of 1 to 10. During the December 2016 Board hearing, the Veteran testified that when she was working, her headaches would last the entire day. She reported that her eyes might hurt or her head might throb, but that she would still try and do her job despite the headaches. The Veteran stated that maybe once a month she would have headaches so severe that she would have to go to bed. She also reported having headaches once or twice a month that were so bad that she could not function and would want to put her head underneath the covers. She stated that a few times a month, she would have headaches that required her to lay down; those headaches were noted to last for the entire day. In a December 2016 statement, the Veteran reported that she had several headaches a week which caused her eyes to hurt. She reported that the headaches were very painful and lasted several hours. The Board observes that the rating criteria do not define "prostrating." Dorland's Illustrated Medical Dictionary defines "prostration" as "extreme exhaustion or powerlessness." See Dorland's Illustrated Medical Dictionary 1531 (32nd ed. 2012). In Stedman's Medical Dictionary 1461 (27th Ed. 2000), "prostration" is defined as "a marked loss of strength, as in exhaustion." Another definition characterizes prostration as "causing extreme exhaustion, powerlessness, debilitation or incapacitation with substantial inability to engage in ordinary activities." The Board also points out that the Court has held that "nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50% rating," and that "[i]f 'economic inadaptability' were read to import unemployability, the appellant, if he met the economic-inadaptability criterion, would then be eligible for a rating of total disability based on individual unemployability resulting from a service-connected disability (TDIU) rather than just a 50% rating." Pierce v. Principi, 18 Vet. App. 440, 446 (2004). In Pierce, the Court explained that where the Board refused to award a 50 percent disability rating for a headache disorder without discussing the "interplay" among the regulations found at 38 C.F.R. § 4.3 (reasonable doubt resolved in favor of claimant), 38 C.F.R. § 4.7 (higher possible evaluation applies "if disability picture more nearly approximates the criteria for that rating[;] otherwise, the lower rating will be assigned"), and 38 C.F.R. § 4.21 (all the elements specified in a disability grade need not necessarily be found although "coordination of rating with impairment of function will, however, be expected in all instances"), the Board committed reasons or bases error. Id. at 445. In addition, the Court acknowledged the Secretary's concession that the phrase "productive of severe economic inadaptability" in DC 8100 should be construed as either "producing" or "capable of producing" severe economic inadaptability. Id. However, in Johnson, supra, the Court clarified that the criteria of DC 8100 are successive, and 38 C.F.R. §§ 4.7 and 4.21 are not for application. Considering the pertinent evidence in light of the applicable rating criteria and considerations, the Board finds that, when reasonable doubt is resolved in favor of the Veteran, the criteria for an initial 50 percent rating is warranted, effective June 21, 2013. Here, the Veteran has credibly testified as to the nature and severity of her headaches. She had reported headaches occurring more than once per month, the severity of which require her to lay down. The descriptive phrase "very frequent" found in the 50 percent rating criteria connotes a frequency at least greater than once a month. This is because DC 8100 is successive, and the criteria for a 30 percent rating connotes a frequency of once a month. See Johnson, 30 Vet. App. at 253. Further, although the Veteran has not specifically asserted extreme exhaustion or powerlessness, having to lay in bed all day suggests to the Board that the Veteran's headaches are capable of such. Further, although the Veteran indicated trying to work through her headaches, she did not report symptoms that the Board finds would interfere with her ability to do her work, such as eye strain and decreased concentration. Moreover, the Board concludes that if the Veteran's prostrating headache attacks occurred twice monthly on work days, they would be capable of producing severe economic inadaptability, as it is likely that the Veteran would have to miss work on those days. Overall, the Board finds that the evidence is thus at least evenly balanced as to whether the Veteran's tension headaches meet each of the criteria for a 50 percent rating under DC 8100. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to the maximum schedular initial 50 percent rating for the Veteran's migraine headaches under DC 8100 is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. REASONS FOR REMAND Regarding the issue of entitlement to a higher initial rating for degenerative arthritis of the right knee (previously rated as chondromalacia, right knee) currently evaluated as 10 percent disabling, as noted, that matter was previously remanded for the Veteran to be afforded a new VA examination to evaluate the severity of her right knee disability. A VA examination was conducted in December 2019. Notably, the report of the examination indicates range-of-motion testing was not conducted due to Veteran's fear of pain. Then, after the claim was returned to the Board in September 2020, the Veteran was afforded a VA knee and lower leg examination in March 2021; the reports of those examinations were subsequently associated with the claims file. In this regard, the Board notes that any additional evidence received by the AOJ after the records have been transferred to the Board for appellate consideration will be forwarded to the Board if it has a bearing on the appellate issue or issues. 38 C.F.R. § 19.37(b). It is for the Board to then determine what action is required with respect to the additional evidence. Id. Here, the Board finds that the March 2021 VA examination report is pertinent to the issue of entitlement to a higher initial rating for the Veteran's right knee disability and, as such, that matter must be remanded for the AOJ to consider this evidence in the first instance. See Disabled American Veterans v. Sec'y of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003) (holding that appellants are denied "one review on appeal to the Secretary" when the Board considers additional evidence without having to remand the case to the AOJ for initial consideration, and without having to obtain the appellant's waiver). Indeed, 38 C.F.R. § 20.1305(c) provides that any pertinent evidence submitted by the appellant or representative which is accepted by the Board under the provisions of this section, as well as any such evidence referred to the Board by the AOJ under 38 C.F.R. § 19.37(b) must be referred to the AOJ for review, unless this procedural right is waived by the appellant or representative, or unless the Board determines that the benefit or benefits to which the evidence relates may be fully allowed on appeal without such referral. Here, to the extent that the Veteran could waive initial consideration by the AOJ of VA-generated evidence, there has been no such waiver in this case. Accordingly, because the March 2021 examination report is pertinent to the issue of entitlement to a higher initial rating for the Veteran's right knee disability, a remand of the claim is required for the issuance of an SSOC. As to the issue of entitlement to a higher rating for cervical strain and degenerative arthritis of the spine, that matter was previously remanded for the Veteran to be afforded a new VA examination to determine that current severity of the condition. In the April 2019 remand action, the Board explained that the report of an April 2018 VA neck conditions examination was not adequate to rely upon because it did not comply with the requirements of Correia v. McDonald, 28 Vet. App. 158, 168 (2016). In December 2019, the Veteran was afforded a new VA neck conditions examination. A review of the examination report reveals that the Veteran complained of worsening symptoms since she was last examined, to include constant dull ache, stiffness, tightness, and limited range of motion in the cervical region. The examiner conducted range-of-motion testing, the results of which were noted to show abnormal or outside of normal range of motion for the cervical spine. The examiner also indicated objective evidence of pain with motion, to include on forward flexion, extension, right and left lateral flexion, and right and left lateral rotation, but made no specific finding as to the degree of range-of-motion loss due to pain on use. Here, it is unclear from the December 2019 examination report at what point the Veteran experienced painful motion. The Court has found similar examination findings to be inadequate because the examiner did not explicitly report "whether and at what point during the range of motion the appellant experienced any limitation of motion that was specifically attributable to pain." Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). The Court stressed that such a finding is important in providing a "clear picture of the nature of the veteran's disability and the extent to which pain is disabling," so as to "allow the Board to ensure that the disabling effects of pain are properly considered when evaluating any functional loss due to pain that is attributable to the veteran's disability." Id. Given the deficiencies in the December 2019 VA examination report, the Board finds that the issue of entitlement to a higher initial rating for the Veteran's disability of the cervical spine must be remanded for the Veteran to be afforded another VA compensation examination to assess the current severity of this disability more definitively. See 38 U.S.C. § 5103A ; 38 C.F.R. § § 3.159; see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Regarding the Veteran's claim for service connection for breathing problems, diagnosed as asthma, the Board previously remanded the matter in April 2019 for the AOJ to obtain an addendum opinion regarding the nature and cause of the Veteran's breathing problems diagnosed as asthma. Specifically, it was requested that an appropriate clinician render an opinion as to whether it is at least as likely as not that the Veteran's asthma began in, or is otherwise related to, the Veteran's military service. The Veteran was afforded a VA respiratory conditions examination in December 2019. Regarding the requested opinion, the clinician stated that the Veteran had subjective symptoms of asthma and that she was unable to determine a diagnosis of asthma from subjective symptoms only, noting that the Veteran was on no current treatment for asthma. Although the clinician opined that the claimed condition was less likely than not incurred in or otherwise caused by service, the underlying rationale was that a current diagnosis of asthma could not be confirmed. Notably, in connection with a claim for an increased rating for her service-connected breathing condition, diagnosed as restrictive lung disease, the Veteran was provided with another VA respiratory conditions examination in January 2021. A review of that examination report reveals a diagnosis of asthma requiring intermittent use of inhaled bronchodilator therapy and daily use of inhaled anti-inflammatory medication. In a February 2021 addendum, the VA clinician stated that the Veteran's asthma was responsible for her need of inhaled medications and that the Veteran's diagnosed asthma is separate and unrelated to her service-connected restrictive lung disease. As evidence associated with the record after the December 2019 VA examination confirms a diagnosis of asthma, the Board finds it necessary to remand the issue of entitlement to service connection for breathing problems, diagnosed as asthma, for the AOJ to obtain a new medical opinion regarding the etiology of the Veteran's diagnosed asthma. This is so because the December 2019 opinion report is inadequate to rely upon in light of the fact that the Veteran now has a confirmed diagnosis of asthma. Regarding the Veteran's claim for a higher initial rating for PTSD, the Board finds that that matter must be remanded for additional development. As noted, the Veteran's PTSD is currently evaluated as 30 percent disabling from March 29, 2005, to September 7, 2010, as 70 percent disabling from September 7, 2010, to March 15, 2013, and as 100 percent disabling from that date forward. Unfortunately, save for treatment records from the Atlanta Vet Center dated from 1999 to 2000, the record contains little medical information pertaining to the Veteran's mental health, to include the severity of any psychiatric symptoms the Veteran was then experiencing, prior to 2010. In January 2010, however, the Veteran presented to a VA Community Based Outpatient Clinic with complaints of longstanding depression. A mental health initial evaluation was completed the following month. At that time, the Veteran reported that she had been depressed on and off for many years, but that her depression had worsened over the past five years and that over the past year, she had been able to do less and less things. The Veteran stated that she slept excessively, had little desire to get up and go to work, did not want to be around anyone, felt tired all the time, and had little interest in hobbies or activities she once enjoyed. The Veteran endorsed weekly panic attacks and recurrent dreams about her past military sexual trauma. During a March 2010 mental health evaluation, the Veteran reported the following psychiatric symptoms: depressed mood; loss of interest; excessive worry; avoidance; hyperarousal; panic attacks; anxiety; flashbacks; and decreased concentration. She stated that she had begun to make a lot of mistakes at work. It was reported that the Veteran was then working full time as a Veterans Service Representative (VSR) at a VARO, a position she had held for the past one and a half years. In June 2010, the Veteran reported that her PTSD symptoms has been triggered by her job, which required her to review PTSD claims dealing with sexual trauma. That same month, the Veteran submitted a statement wherein she reported having memory problems. She also stated that she was irritable at work, and that termination from her job was consistently a threat due to her PTSD symptoms. She also related that she did not leave the house or ride elevators with men, that she avoided being in the back of a vehicle, and that she did not brush her hair or wear makeup. Also of record is a July 2010 certification from the Veteran's VA staff psychiatrist, K.J.S., M.D., who reported that the Veteran had a serious health condition under the Family and Medical Leave Act (FMLA). It was noted that the Veteran was suffering from intrusive memories about her past trauma, hypervigilance, avoidance of triggers associated with the memories, insomnia, isolation and withdrawal, exaggerated startle response, depressed mood, irritability, anhedonia, poor concentration and focus, excessive guilt, and recurrent distressing distress. Dr. J. stated that that aspects of the Veteran's then-current job had triggered a worsening of her symptoms, and that the symptoms has been present for a minimum of one and year years. Dr. J. advised that the Veteran would benefit from a decreased work schedule of no more than 20 hours per week. In a statement dated September 7, 2010, Dr. J. opined that the Veteran's PTSD symptoms resulted in restricted ability with establishing and maintaining effective relationships, adapting to stressful circumstances in the workplace, remembering salient details, and making sound judgments. Based on the Dr. J.'s September 2010 statement, the AOJ assigned a 70 percent rating for the Veteran's PTSD; a 30 percent rating was maintained prior to the date. However, the Board finds that the evidence suggests that the increase in disability arose prior to September 7, 2010. Indeed, it would appear as though the increase in disability corresponds to when the Veteran began her role as a VSR at the Atlanta VARO. Although it is indicated in January 2010 that she had held that position for the past one and a half years, her exact beginning date of employment at a VSR is not clear from the record currently before the Board. Thus, the Board finds it necessary to remand the matter for the AOJ to attempt to obtain the Veteran's employment information from VA and/or to allow for the Veteran to submit this information. This information is necessary to ensure that the Board decision is a fully informed one. Lastly, as any decision regarding the Veteran's remanded claims for higher ratings for PTSD, a right knee disability, and/or a cervical spine disability may impact the Veteran's eligibility for DEA benefits, the Board finds it necessary to also remand the issue of entitlement to an earlier effective date for the establishment of basic eligibility for DEA. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). The matters are REMANDED for the following action: 1. Verify the dates of the Veteran's employment as a VSR with the VARO in Atlanta, Georgia, to specifically include the date upon which she began employment in the role. If such information cannot be released without the Veteran's authorization, the Veteran should be requested to provide the necessary authorizations to release of this information to VA. 2. Arrange for the Veteran to undergo a VA cervical spine examination by an appropriate clinician. The Veteran's claims file must be made available to the designated individual, and the examination report should reflect full consideration of the Veteran's documented medical history and assertions. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner should provide a complete assessment of the severity of the Veteran's service connected cervical spine disability. The examiner should conduct range of motion testing (reported in degrees). Specifically, the examiner should test the range of motion in active motion, passive motion, weight bearing, and non-weight bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly so state, and explain why. In conducting range of motion testing, the examiner should render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination. If pain on motion is observed, the examiner must indicate the point at which motion limiting pain begins. In addition, if the examination is not conducted during a flare up, the examiner should indicate whether, and to what extent, the Veteran experiences likely functional loss in the neck to pain and/or any of the other symptoms noted above during flare-ups and/or with repeated use; to the extent possible, the examiner should express any such additional functional loss in terms of additional degrees of limited motion. The examiner should specifically indicate whether there is any ankylosis. The examiner should also state whether there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. All examination findings/testing results, along with a complete, clearly-stated rationale for the conclusions reached, must be provided. 3. Arrange to obtain from an appropriate clinician further etiology opinion for the Veteran's asthma based on claims file review. (Only arrange for the Veteran to undergo a VA examination if one is deemed necessary in the judgment of the clinician(s) designated to provide the addendum opinions.) The Veteran's claims file must be made available to the designated individual, and the addendum opinion report should reflect consideration of the Veteran's documented medical history and assertions Upon review of the evidence, the clinician should provide an opinion as to whether it at least as likely as not (i.e., a 50 percent or greater probability), that the Veteran's asthma had its onset during service or is otherwise medically related to the Veteran's service. In providing the opinion, the clinician must consider all relevant medical and lay evidence of record, to specifically include the Veteran's statement in her June 2008 notice of disagreement that she had treatment breathing problems in 1976 and 1977, and believes she was exposed to asbestos in 1979 or 1980. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about her symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? A complete, clearly stated rationale for all opinions expressed must be provided. Notably, the absence of documented evidence of the current disabilities in service or shortly after service should not, alone, serve as the sole basis for a negative opinion. Rather, if it is determined that the Veteran's competent assertions as to the nature, onset, and continuity of symptoms do not support a finding of service connection, the clinician must set forth specific reasons why not. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Neilson, 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.