Citation Nr: 22000801 Decision Date: 01/06/22 Archive Date: 01/06/22 DOCKET NO. 16-50 338 DATE: January 6, 2022 ORDER Entitlement to a compensable disability rating for service-connected bilateral hearing loss denied. Entitlement to a disability rating in excess of 30 percent for service-connected asthma is denied. Entitlement to an initial disability rating in excess of 30 percent for service-connected chronic headaches is denied. Entitlement to service connection for a disability manifested by hair loss, claimed as due to an undiagnosed illness, is denied. REMANDED Entitlement to a disability rating in excess of 10 percent for service-connected idiopathic peripheral neuropathy of right lower extremity prior to February 1, 2020 is remanded. Entitlement to a disability rating in excess of 10 percent for service-connected idiopathic peripheral neuropathy of the left lower extremity prior to February 1, 2020 is remanded. Entitlement to service connection for a disability manifested by chronic joint pain and stiffness, claimed as due to an undiagnosed illness and/or as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a disability manifested by chronic fatigue, claimed as due to an undiagnosed illness and/or as secondary to service-connected PTSD, is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to an undiagnosed illness and/or as secondary to service-connected PTSD, is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's bilateral hearing loss was productive of no worse than Level II hearing impairment in the right ear and Level II hearing impairment in the left ear. 2. Throughout the appeal period, the Veteran's asthma has not been manifested by a FEV-1 of 55 percent or less predicted or FEV-1/FVC 55 percent or less nor has it required at least monthly visits to a physician for care of exacerbations or at least three courses of systemic oral or parenteral corticosteroids in any 12 month period. 3. Throughout the appeal period, the Veteran's chronic headaches have manifested as characteristic prostrating attacks occurring on an average of once a month over the last several months. 4. The preponderance of the evidence is against finding that the Veteran has a disability manifested by hair loss that was caused or aggravated by his active military service. CONCLUSIONS OF LAW 1. The criteria for a compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.85, Diagnostic Code (DC) 6100. 2. The criteria for a disability rating in excess of 30 percent for asthma have not been met. 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.10, 4.97, DC 6602. 3. The criteria for an initial disability rating in excess of 30 percent for chronic headaches have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.124a, DC 8100. 4. The criteria for service connection for a disability manifested by hair loss have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1986 to June 1991. He served in Southwest Asia during the Gulf War. The majority of the issues in this case come before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This decision was appealed in a notice of disagreement (NOD) received by VA in January 2015. A statement of the case (SOC) was issued in September 2016. The Veteran filed a VA Form 9 in September 2016. The claim for an initial rating greater than 30 percent for headaches comes before the Board on appeal from a rating decision issued in August 2016. This claim was appealed in a NOD received by VA in September 2016. A SOC was issued by VA in May 2019. VA received the Veteran's VA Form 9 in June 2019. The Veteran appeared before the undersigned Veterans Law Judge at a videoconference hearing in February 2020. A transcript of that hearing has been added to the record. In a December 2020 Board decision, the claims were remanded for further evidentiary development. A supplemental statement of the case (SSOC) was issued in July 2021. The Veteran's VA claims file has been returned to the Board for further appellate proceedings. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. §§ 3.102, 4.3. In general, when 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, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claims. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The Board has considered all evidence of record as it bears on the issue before it. See 38 U.S.C. § 7104(a) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. 1. Entitlement to a compensable disability rating for service-connected bilateral hearing loss. Impairment of auditory acuity (hearing loss) is evaluated pursuant to the provisions set forth at 38 C.F.R. § 4.85. Under that regulation, an examination for hearing impairment must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. Examinations are to be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). To evaluate the degree of disability from defective hearing, the Rating Schedule establishes 11 auditory acuity levels from Level I, for essentially normal acuity, through Level XI, for profound deafness. These are assigned based on a combination of the percent of speech discrimination and the pure tone threshold average, as contained in a series of tables within the regulations. 38 C.F.R. § 4.85(b). The pure tone threshold average is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz (Hz), divided by four. This average is used in all cases to determine the Roman numeral designation for hearing impairment from Table VI or VIA. 38 C.F.R. § 4.85(d). Table VII, Percentage Evaluations for Hearing Impairment, is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal rows represent the ear having the better hearing and the vertical columns the ear having the poorer hearing. The percentage evaluation is located at the point where the row and column intersect. 38 C.F.R. § 4.85(e). In cases where impaired hearing is service-connected in only one ear, in order to determine the percentage evaluation from Table VII, the non-service-connected ear will be assigned a Roman Numeral designation for hearing impairment of I, subject to the provisions of 38 C.F.R. § 3.383. 38 C.F.R. § 4.85(f). The regulatory provisions also provide two additional circumstances under which alternative tables can be employed. One is where the pure tone thresholds of the frequencies of 1000, 2000, 3000, and 4000 Hz are 55 decibels or greater. The second is where pure tone thresholds are 30 decibels or less at frequencies of 1000 Hz and below, and are 70 decibels or more at 2000 Hz. See 38 C.F.R. § 4.86. As indicated above, the Veteran is assigned a noncompensable disability rating for bilateral hearing loss throughout the appeal period. He has asserted that a higher disability rating is warranted. As will be explained below, the resolution of this issue involves determining the levels of hearing acuity. The Veteran was afforded a VA audiology examination in April 2014 at which time the examiner noted the following pure tone thresholds: HERTZ 1000 2000 3000 4000 Average RIGHT 35 35 45 70 46.25 LEFT 35 40 50 55 45 Average pure tone threshold was 46.25 decibels in the right ear and 45 in the left ear. Speech recognition scores were 88 percent in the right ear and 92 percent in the left ear. The examiner stated that the Veteran's bilateral hearing loss does impact the ordinary conditions of his daily life, including his ability to work. The examiner reported that the Veteran has difficulty hearing conversations and has to constantly ask others to repeat themselves. The Veteran described increased trouble hearing with background noise and he stated that he must turn up the volume to hear the television. Such examination findings translate to level II hearing impairment in the left ear and level I hearing in the left ear. 38 C.F.R. § 4.85, Table VI. Applying Table VII, DC 6100, this equates to a noncompensable (zero percent) rating. The Veteran was afforded a VA audiology examination in August 2014, which documented the following pure tone thresholds: HERTZ 1000 2000 3000 4000 Average RIGHT 50 45 55 60 53 LEFT 45 45 65 60 54 Average pure tone threshold was 53 decibels in the right ear and 54 in the left ear. Speech recognition scores were 92 percent in the right ear and 88 percent in the left ear. The examiner stated that the Veteran's bilateral hearing loss does impact the ordinary conditions of his daily life, including his ability to work. The examiner explained that the Veteran "wears his hearing aids when he is home and out with family and friends. He does not wear them at work where he wears hearing protection." The August 2014 VA examination findings translate to level I hearing impairment in the right ear and level II hearing in the left ear. 38 C.F.R. § 4.85, Table VI. Applying Table VII, DC 6100, this equates to a noncompensable (zero percent) rating. An April 2018 VA audiology examination documented the following pure tone thresholds: HERTZ 1000 2000 3000 4000 Average RIGHT 45 45 50 60 50 LEFT 45 45 55 55 50 Average pure tone threshold was 50 decibels in the right ear and 50 in the left ear. Speech recognition scores were 96 percent in the right ear and 94 percent in the left ear. The examiner stated that the Veteran's bilateral hearing loss does impact the ordinary conditions of his daily life, including his ability to work. The Veteran reported, "[m]y quality of life is crappy. I need the TV too loud and I need everything loud. I have to ask people to repeat all the time and I can't hear when I wear hearing protection." He further stated, "I have difficulty hearing on the phone even with hearing aids." The April 2018 VA examination findings translate to level I hearing impairment in the right ear and level I hearing in the left ear. 38 C.F.R. § 4.85, Table VI. Applying Table VII, DC 6100, this equates to a noncompensable (zero percent) rating. Pursuant to the December 2020 Board remand, the Veteran was afforded a VA audiology examination in March 2021, which documented the following pure tone thresholds: HERTZ 1000 2000 3000 4000 Average RIGHT 50 50 60 70 57.5 LEFT 55 55 60 70 60 Average pure tone threshold was 57.5 decibels in the right ear and 60 in the left ear. Speech recognition scores were 94 percent in the right ear and 94 percent in the left ear. The examiner stated that the Veteran's bilateral hearing loss does impact the ordinary conditions of his daily life, including his ability to work. The examiner explained that the Veteran "must ask people to repeat themselves all the time. He used hearing aids provided by the VA. His wife is hard to understand. He must turn the TV up very loud." The March 2021 VA examination findings translate to level II hearing impairment in the right ear and level II hearing in the left ear. 38 C.F.R. § 4.85, Table VI. Applying Table VII, DC 6100, this equates to a noncompensable (zero percent) rating. Accordingly, the medical evidence of record demonstrates that throughout the appeal period, the Veteran's bilateral hearing loss warrants a noncompensable rating pursuant to DC 6100. 38 C.F.R. § 4.85. There is no audiological evidence of record to support a compensable disability rating for the Veteran's bilateral hearing loss disability. The Board therefore concludes that the evidence substantially weighs against the claim and it is denied. 38 U.S.C. § 5107(b); see also Lynch v. McDonough, No. 2020-2067 (Fed. Cir. Dec. 17, 2021). The Board in no way discounts the difficulties that the Veteran experiences as a result of his service-connected bilateral hearing loss disability. In this regard, it must be emphasized that the disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designation assigned after audiometry results are obtained. Hence, the Board must base its determination on the results of the pertinent and valid audiology studies. See Lendenmann, 3 Vet. App. at 345. In other words, the Board is bound by law to apply VA's rating schedule based on the Veteran's audiometry results. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Under these circumstances, the Board finds that the record presents no basis for assignment of a higher disability rating. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. The Board finds that the rating criteria contemplate the Veteran's bilateral hearing loss disability. His hearing loss is manifested by decreased hearing acuity which causes problems such as having to turn the television up and asking others to repeat themselves. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology, including his difficulty hearing and understanding speech. The Board notes that this conclusion is consistent with the Court's holding in Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) ("[W]hen a claimant's hearing loss results in an inability to hear or understand speech or to hear other sounds in various contexts, those effects are contemplated by the schedular rating criteria"). Because the rating criteria reasonably describe the claimant's disability level and symptomatology, the Veteran's disability picture is contemplated by the Rating Schedule, such that the schedular evaluation now assigned is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115-116 (2008); VAOPGCPREC 6-96. The evidence does not show anything unique or unusual about the Veteran's bilateral hearing loss that would render the schedular criteria inadequate. 2. Entitlement to a disability rating in excess of 30 percent for service-connected asthma. The Veteran's service-connected asthma has been rated pursuant to DC 6602, which contemplates bronchial asthma. Under DC 6602, a 30 percent evaluation is warranted for an FEV-1 of 56 to 70 percent of predicted value, or, an FEV-1/FVC of 56 to 70 percent, or, daily inhalational or oral bronchodilator therapy, or, inhalational anti-inflammatory medication. A 60 percent evaluation is warranted for an FEV-1 of 40 to 55 percent of predicted value, or, an FEV-1/FVC of 40 to 55 percent, or, at least monthly visits to a physician for required care of exacerbations, or, intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A maximum 100 percent disability rating is assigned for an FEV-1 less than 40 percent of the predicted value, or, FEV-1/FVC less than 40 percent, or, more than one attack per week with episodes of respiratory failure, or, requires daily use of systemic (oral or parenteral) high dose corticosteroids or immune-suppressive medications. 38 C.F.R. § 4.97, DC 6602. Pulmonary Function Test (PFT) results are generally reported before and after the administration of bronchodilator therapy. VA regulations require the use of post-bronchodilator results in determining disability ratings for Diagnostic Codes 6600, 6603, 6604, 6825-6833, and 6840-6845, unless post-bronchodilator results are poorer than pre-bronchodilator results. 38 C.F.R. § 4.96(d)(4). There are no regulations specifying whether pre- or post-bronchodilator results should be used when determining disability ratings under DC 6602. As a matter of convenience, this decision relates pre- and post-bronchodilator scores alike in summarizing PFT studies. In evaluating individual PFT findings (FEV-1, FVC, etc.) under DCs 6600, 6603, 6604, 6825-6833, and 6840-6845, the Board must employ the result which the testing physician states most accurately reflects the Veteran's level of disability, when the disparity between this result and other PFT findings would support different disability ratings. 38 C.F.R. § 4.96(d)(6). No similar regulation directs the use of disparate PFT findings. Historically, the Veteran was awarded service connection for asthma in a March 1992 rating decision; a 10 percent disability rating was assigned. In an August 1996 rating decision, the assigned rating was increased to 30 percent. The Veteran filed a claim of entitlement to an increased disability rating for asthma in May 2014, which was denied in a December 2014 rating decision. He filed a NOD in January 2015 and this appeal follows. VA treatment records dated in December 2013 documented the Veteran's report of steadily worsening asthma, which has accelerated in the last several months. The Veteran indicated that his wheezing is highly variable, even while he is taking medication regularly. Now, he may be wheezing while sitting. He has used his albuterol nebulizer an average of 5 to 6 times per day in the last month or so. The Veteran reported that his activity is limited primarily by asthma. The Veteran was afforded a VA respiratory examination in March 2014 at which time the examiner confirmed a continuing diagnosis of asthma. The Veteran reported that his shortness of breath increased since his last VA examination in January 2012. He reported that his asthma was treated orally with Prednisone for 10 days in January 2014. Aside from that instance, the examiner reported that the Veteran's asthma has not required the use of oral or parental corticosteroid medications. The Veteran's asthma has required the use of daily inhalational bronchodilator therapy, as well as daily inhalational anti-inflammatory medication, and tiotropium. His asthma is also treated with the daily use of oral bronchodilators. The Veteran's asthma has not required the use of oxygen therapy. He has not experienced asthma attacks with episodes of respiratory failure in the past 12 months. A March 2014 chest x-ray revealed no acute cardiopulmonary disease. PFT results from March 2014 revealed pre-bronchodilator FVC at 79 percent predicted; FEV-1 at 69 percent predicted, FEV-1/FVC at 70 percent predicted, and DLCO at 95 percent predicted. Post-bronchodilator FVC was 81 percent predicted, FEV-1 at 76 percent predicted, and FEV-1/FVC at 70 percent predicted. The examiner reported that the Veteran's asthma does impact his ability to work. To this end, the Veteran "indicates outdoor work at extremes of temperatures as well as requiring a lot of exertion are problematic." A March 2014 VA pulmonary consultation documented the Veteran's report of shortness of breath/dyspnea on exertion; he indicated that he can only walk a half of a block before stopping. The Veteran has occasional cough, chest tightness, and wheezing. His symptoms are worsened by dust, vapors, and exercise. The Veteran stated that he takes an ambulance to the emergency department approximately ten times per year for his asthma symptoms. The treatment provider indicated that, apparently the Veteran has a connection with Emergency Medical Services (EMS) because he works in law enforcement, which allows him to use the ambulance in this regard. He has never been admitted to the hospital or intubated, but he has received several courses of Prednisone. The Veteran uses his albuterol nebulizer 2 to 3 times per day and his Proventil inhaler 3 to 4 times per day, which improves his symptoms. He also uses Atorvent, Theophylline, and Singulair. Another VA respiratory examination was conducted in September 2014, at which time the Veteran reported the daily use of inhalational bronchodilator therapy, as well as inhalational anti-inflammatory medication. He uses his albuterol inhaler several times a day, as well as a nebulizer several times daily. The Veteran reported that he previously had a job that allowed him to receive "unofficial" nebulizer treatments from the emergency room. He stated that his "breathing typically worsens with exertion which can affect playing with grandkids and very physical activities." The Veteran's asthma has required intermittent courses or bursts of systemic corticosteroids once time in the past 12 months. He does not require oxygen therapy and has not had asthma attacks with respiratory failure in the last 12 months. The Veteran has not had any physician visits as required care for exacerbations. He reported that the Veteran's asthma does impact his ability to work; specifically, the "Veteran notes that breathing typically worsens with exertion which can affect playing with the grandkids and very physical activities, especially outdoors in the heat." The September 2014 VA examiner did not conduct pulmonary function testing. In a July 2017 email to his VA primary care physician, the Veteran reported experiencing severe breathing issues of three weeks duration. He indicated that temperatures over 100 degrees have kept him in his house, fighting for air. However, treatment records show that the Veteran did not respond to the treatment provider's attempts to schedule an appointment in response to the July 2017 communication. The Veteran was afforded a VA examination in February 2018 to assess the severity of his service-connected asthma. The examiner reported that the Veteran's asthma does not require the use of oral or parenteral corticosteroid medications. He does use daily inhalational bronchodilator therapy, as well as daily oral bronchodilators. The Veteran's asthma does not require the use of antibiotics or out-patient oxygen therapy. The examiner indicated that the Veteran has had four or more asthma attacks with episodes of respiratory failure in the past 12 months; however, the Veteran has not required physician visits for care of his exacerbations. The examiner reported that the Veteran does not experience incapacitating episodes due to his asthma. He does not have any cardiopulmonary complications. The examiner reported that the Veteran's asthma does impact his ability to work. The examiner noted eth Veteran's report that "he has to keep his nebulizer plugged at work, ready to use when he has an exacerbation of his asthma. The Veteran reports shortness of breath and wheezing with very little exertion. The Veteran can perform light physical and sedentary activities." Pulmonary function testing was not performed at the February 2018 VA examination. VA treatment records dated in April 2019 document the Veteran's report that his asthma has gradually worsened. Pursuant to the December 2020 Board Remand, the Veteran was afforded a VA respiratory examination in May 2021. The examiner reported that the Veteran's asthma does not require the use of oral or parenteral corticosteroid medications. His asthma is treated with daily inhalational bronchodilator therapy and daily inhalational anti-inflammatory medication. The Veteran also reported the use of Ipotropium and the daily use of oral bronchodilators to manage his asthma symptoms. The Veteran's asthma does not require the use of antibiotics or out-patient oxygen therapy. He has not had asthma attacks with episodes of respiratory failure in the past 12 months. PFT was performed, which revealed the following pre-bronchodilator results: FVC at 67 percent predicted, FEV-1 at 66 percent, FEV-1/FVC at 77 percent; and DLCO at 91 percent. The following post-bronchodilator results were also shown: FVC at 83 percent predicted, FEV-1 at 82 percent, and FEV-1/FVC at 77 percent. The examiner reported that the test result, which most accurately reflects the Veteran's level of disability is FEV-1/FVC. The examiner reported that the Veteran's asthma does impact his ability to work. Specifically, he "must be able to work in environments where he is able to carry and use his inhalers." Based on the record, the Board finds that a clear preponderance of the evidence is against the assignment of a disability rating in excess of 30 percent for the Veteran's asthma at any point during the appeal period. In this regard, the Veteran's asthma is not shown to have been manifested by an FEV-1 of 40 to 55 percent of predicted value, or an FEV-1/FVC of 40 to 55 percent, or at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids, as would warrant a 60 percent rating under DC 6602. The Board recognizes that the September 2014 VA examiner noted that the Veteran has required one course/burst of systemic corticosteroids in the past 12 months. No other VA examiner has documented any continuing treatment with corticosteroids for the Veteran's asthma symptoms. Notably, the September 2014 VA examiner did not indicate that the corticosteroid use occurred three times per year, which would warrant a 60 percent rating under DC 6602. The Board additionally observes that the February 2018 VA examiner reported the Veteran had four or more asthma attacks with episodes of respiratory failure in the past 12 months. However, this finding is not supported by the medical evidence of record, which does not document treatment for episodes of respiratory failure. In fact, the February 2018 VA examiner additionally reported that the Veteran did not require physician visits for asthma exacerbations. As such, the Board finds the February 2018 notation concerning asthma attacks with respiratory failure to be an outlier, unsupported by the other clinical findings of record. It does not accurately depict the severity of the Veteran's asthma symptoms throughout the entire appeal period. A disability can have inactive and active stages, requiring the application of staged ratings. Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994). However, in Voerth v. West, the Court found Ardison inapplicable where the veteran's disability, in its recurrent state, did not affect his earning capacity and the worsened condition did not last more than a few days. 13 Vet. App. 117, 122-23 (1999) (holding that condition that became inflamed approximately twice a year for a few days did not require examination during flare up). Moreover, there is no documentation that the Veteran's asthma caused more than one attack per week with episodes of respiratory failure, such as would warrant a 100 percent rating under DC 6602. The Board has considered the statements of the Veteran as to the extent of his asthma symptoms. The Veteran is competent to describe the severity of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Accordingly, the Board finds that a clear preponderance of the evidence is against the assignment of a disability rating in excess of 30 percent for the Veteran's service-connected asthma, and the claim must be denied. 38 U.S.C. § 5107(b); see also Lynch v. McDonough, No. 2020-2067 (Fed. Cir. Dec. 17, 2021). 3. Entitlement to an initial disability rating in excess of 30 percent for service-connected chronic headaches. The Veteran's chronic headaches have been rated pursuant to DC 8100 [migraine headaches]. Under DC 8100, a 10 percent rating is assigned for migraine headaches manifested by characteristic prostrating attacks averaging one in two months, over the last several months. A 30 percent rating is assigned with characteristic prostrating attacks occurring on an average of once a month over the last several months. Finally, a 50 percent rating is assigned when migraines with very frequent, completely prostrating headaches with prolonged attacks that are productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. The rating criteria do not define "prostrating." The Board additionally observes that the Court has not undertaken to define "prostrating." See Fenderson v. West, 12 Vet. App. (1999), in which the Court quoted DC 8100 verbatim but did not specifically address the matter of what is a prostrating attack. By way of reference, the Board notes that according to DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), "prostration" is defined as "extreme exhaustion or powerlessness;" and according to STEDMAN'S MEDICAL DICTIONARY 1461 (27th Ed. 2000), "prostration" is defined as "a marked loss of strength, as in exhaustion." In this matter, the Veteran was awarded service connection for chronic headaches in an August 2016 rating decision, which assigned a 30 percent rating from May 2, 2014. In September 2016, he filed a NOD as to the assigned initial disability rating and this appeal follows. For the reasons set forth below, the Board concludes that a disability rating in excess of 30 percent is not warranted for the Veteran's chronic headaches at any time from the date of service connection. In a July 2012 VA Gulf War examination, the Veteran reported headaches manifested by constant head pain. He described the pain as pulsating or throbbing, occurring on both sides of his head. The examiner indicated that the Veteran did not experience characteristic prostrating attacks of headache pain. The examiner further reported that the Veteran's headaches had no impact on his ability to work. The Veteran was afforded a VA examination as to his reported headaches in November 2014. The examiner diagnosed the Veteran with chronic daily headaches. The examiner explained that the Veteran reported constant headaches without relief since Christmas 1990. The Veteran's headaches "tend to migrate around in various regions of the head on all sides of the head on a daily basis, and are generally stabby/throbbing." The Veteran previously treated his headaches with Tylenol, but it did not help. He described "the headaches as being severe at times, but did not affect function." Magnetic resonance imaging (MRI) in March 2014 revealed an essentially normal brain. The VA examiner reported that the Veteran did not experience characteristic prostrating attacks of headache pain. The examiner further indicated that the Veteran's headaches do not impact his ability to work. A June 2016 VA examination addressed the Veteran's chronic daily headaches, which continued to occur constantly on both sides of his head. The Veteran described the headache pain as pulsating or throbbing. He endorsed nausea with his headaches. The examiner indicated that the Veteran does experience characteristic prostrating attacks of headache pain, an average of once every month. However, the Veteran does not have very prostrating and prolonged attacks of headache pain productive of severe economic inadaptability. The examiner reported that the Veteran's chronic headaches do not impact his ability to work. The examiner explained, "[t]he Veteran does not experience incapacitating headaches. If prostrating is defined [as] incapacitating, the Veteran does not meet that criteria, however, he has frequent significant exacerbations of headaches that prompt him to alter his activities if the opportunity presents." VA treatment records dated in April 2019 indicated that the Veteran's headaches are worsening. The Veteran reported, "[t]he headaches come and go, and have become more severe." Pursuant to the December 2020 Board Remand, the Veteran was afforded a VA examination as to his headaches in May 2021. The VA examiner noted that the Veteran "[w]akes with headaches, sometimes one-sided, sometimes all over. His work allows him to go in a dark supply closet 1-2 times a day for 12-30 minutes." The Veteran reported that his constant headaches become more severe 1 to 2 times per day, with exacerbations lasting for 15-30 minutes. His headaches are treated with Ibuprofen and Meloxicam. The Veteran endorsed sensitivity to light and sound, as well as nausea during his headaches. The examiner reported that the Veteran does have characteristic prostrating attacks of headache pain. However, he does not experience very prostrating and prolonged attacks of pain, productive of severe economic inadaptability. The examiner indicated that the Veteran's headaches do impact his ability to work. He "[m]ust work in an environment where he can leave his work area at will for 12-30 minutes up to twice a day to lay down in a dark, quiet room." The examiner explained that the Veteran reported, "he always has a headache, it is 'never not there' and has been present since 1991. His records note that he has been employed full-time in a sheriff's department and as a fabricator and has also done moonlighting work on top of that. His functional impact appears to be minimal." In weighing the clinical and lay evidence of record, the Board finds that the Veteran's chronic headaches are manifested by characteristic prostrating attacks occurring on average once a month. The evidence reflects that the chronic headache symptoms do not more nearly approximate very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The Veteran has consistently described experiencing constant headache pain with daily exacerbations. These exacerbations require him to recover in a dark room for 12 to 30 minutes. However, as noted by the May 2021 VA examiner, the Veteran continues to work, despite daily constant headache pain. In Pierce v. Principi, 18 Vet. App. 440 (2004), the Court held 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. 18 Vet. App. at 445. The Court also examined the "productive of severe economic inadaptability" criterion for a 50 percent rating under DC 8100 and noted that "[n]owhere in the DC is 'inadaptability' defined, nor can a definition be found elsewhere in title 38 of the [C.F.R.]." Id. at 446. The Court explained that, contrary to the VA's argument, "nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating" because "[i]f 'economic inadaptability' were read to import unemployability," a claimant who "met the economic-inadaptability criterion, would then be eligible for a rating of total disability based on individual unemployability [(TDIU)]....rather than just a 50% rating." Id. The Court therefore rejected the notion that "severe economic inadaptability" was equivalent to an inability to secure or follow a substantially gainful occupation, the unemployability standard for TDIU. Id. (citing 38 C.F.R. § 4.16 (a)). In addition, the Court in Pierce acknowledged VA'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. at 445. The above evidence shows that the Veteran's chronic headache pain occurs constantly, and has been described as intermittently severe. Crucially, the fact that the Veteran must recover from daily exacerbations in a dark room 1 to 2 times per day for 12 to 30 minutes is not reflective of symptoms more nearly approximating severe economic inadaptability. While the phrase "productive of severe economic inadaptability" in DC 8100 should be construed to include "capable of producing" severe economic inadaptability, the Board finds that the Veteran's chronic headaches are not capable of producing severe economic inadaptability at this juncture. Significantly, he has continued his employment and to date, his headaches have not been shown to produce or be capable of producing severe economic inadaptability. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected chronic headaches, the evidence shows no distinct periods of time from the date of service connection, when his disability varied to such an extent that a rating greater or less than 30 percent would be warranted. Hart, supra. For the foregoing reasons, the criteria for an initial disability rating in excess of 30 percent for chronic headaches have not been met. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b), 38 C.F.R. § 4.3. 4. Entitlement to service connection for a disability manifested by hair loss, claimed as due to an undiagnosed illness. In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation; lay assertions of medical status do not constitute competent medical evidence for these purposes. Lay assertions, however, may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. As it is undisputed that the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established on a presumptive basis under 38 C.F.R. § 3.317. Under this regulation, service connection is presumed for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011. See 38 U.S.C. § 1117(a)(1)(A); 38 C.F.R. § 3.317(a). For purposes of 38 C.F.R. § 3.317, there are three types of "qualifying chronic disabilities" (1) an undiagnosed illness; (2) medically unexplained chronic multi-symptom illness (MUCMI); and (3) a diagnosed illness that the Secretary of VA determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. A MUCMI is "an illness...where either the etiology or pathophysiology of the illness is inconclusive. [A] multisymptom illness[, however,] is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood." Stewart v. Wilkie, 30 Vet. App. 383 (2018). Signs and symptoms that may be a manifestation of an undiagnosed illness or a MUCMI include fatigue, unexplained rashes, headaches, muscle and joint pain, neurological and neuropsychological problems, respiratory problems, sleep disturbances, and gastrointestinal problems. 38 U.S.C. § 1117(g); 38 C.F.R. § 3.317. Here, the Veteran essentially contends that he suffers from hair loss as a result of his Persian Gulf War service. See the Board hearing transcript dated February 2020. Specifically, he asserts that he began losing clumps of his hair upon his return from service in the first Persian Gulf War. Id. For the reasons set forth below, the Board finds that entitlement to service connection for hair loss is not warranted. As indicated above, the Veteran served on active duty from January 1986 to June 1991. Service in Southwest Asia is indicated by the record. The Veteran's service treatment records (STRs), however, do not document any complaints related to hair loss. Post-service treatment records dated in February 1994 indicate that the Veteran reported a history of hair loss, in which his hair comes out in chunks. The treatment provider, however, observed that the Veteran exhibited "no visible, patchy areas of loss." The Veteran also reported hair loss on a Persian Gulf Registry Code Sheet dated in October 1994. Pursuant to the December 2020 Board Remand, the Veteran was afforded a VA examination in May 2021 to address his claimed hair loss. The examiner noted the Veteran's report that, "[w]hen he got back from Iraq during Desert Storm, he started losing his hair in clumps. He was seen but didn't have any testing or treatment for it." The examiner examined the Veteran and reviewed his medical history. The examiner reported, "[t]he Veteran has male pattern hair loss, but no pathological alopecia. [He] is not bald, but has thinning at the crown and temples. He did his own tug test without prompting and could not get any hair to come out." In a separate May 2021 VA medical opinion, the VA examiner indicated that physical examination of the Veteran as well as review of his medical history documented no objective findings to support a diagnosis of pathological alopecia. The examiner explained that the Veteran "has typical male pattern hair thinning, with thin hair on crown and temples common for his age." The VA examiner therefore concluded that the Veteran's claimed hair loss is less likely than not due to his active military service. When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Court has held that claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Regarding the Veteran's claimed hair loss, the Board finds that the clear preponderance of the evidence is against the claim. The Board finds that the most probative evidence, the May 2021 VA medical opinion, establishes that the Veteran does not exhibit a qualifying chronic disability manifested by hair loss. Rather, his hair loss symptoms have been attributed to diagnosed male pattern baldness. The May 2021 VA examiner indicated that the Veteran's hair loss is not due to his active military service. Significantly, the findings of the May 2021 VA examiner were explained and supported by the evidence of record. To this end, the Board notes that the VA examiner's opinion was based on a complete review of the record, including the lay statements and the Veteran's medical history, and the reviewer explained the reasons for her conclusion based on an accurate characterization of the evidence of record. The Board therefore places significant weight on the findings of the May 2021 VA examiner. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Moreover, the Veteran has not produced a medical opinion to contradict the conclusions of the May 2021 VA examiner. Considering the overall evidence, including the post-service medical evidence, the VA examination report and medical opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran's claim that he suffers from an undiagnosed illness manifested by hair loss, which is related to his military service. Thus, the benefit-of-the-doubt rule is not applicable to the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. REASONS FOR REMAND 5. Entitlement to a disability rating in excess of 10 percent for service-connected idiopathic peripheral neuropathy of right lower extremity prior to February 1, 2020 is remanded. 6. Entitlement to a disability rating in excess of 10 percent for service-connected idiopathic peripheral neuropathy of the left lower extremity prior to February 1, 2020 is remanded. In the December 2020 decision, the Board remanded the claims of entitlement to increased disability ratings for service-connected peripheral neuropathy of the right and left lower extremities prior to February 1, 2020 for a VA examination. In pertinent part, the VA examiner was instructed to render an assessment of the severity of the Veteran's condition during the period prior to the severance should be made. Pursuant to the December 2020 Board Remand, a VA examination was conducted in May 2021 as to the Veteran's peripheral neuropathy claims. The examiner rendered findings as to the current severity of the Veteran's peripheral neuropathy; however, the examiner did not provide an opinion concerning the severity of the Veteran's peripheral neuropathy disabilities prior to February 1, 2020. Accordingly, due to the inadequacy of the May 2021 VA medical opinion, the RO failed to ensure substantial compliance with the Board's December 2020 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). These matters must therefore be remanded in order to afford the Veteran a new VA medical opinion as to his higher increased ratings claim. 7. Entitlement to service connection for a disability manifested by chronic joint pain and stiffness, claimed as due to an undiagnosed illness and/or service-connected PTSD. 8. Entitlement to service connection for a disability manifested by chronic fatigue, claimed as due to undiagnosed illness and/or service-connected PTSD. 9. Entitlement to service connection for GERD, to include as due to an undiagnosed illness and/or service-connected PTSD. The Veteran's claims of entitlement to service connection for chronic joint pain and stiffness, chronic fatigue, and GERD were remanded by the Board in December 2020 in order to obtain VA medical opinions regarding the etiology of the claimed disabilities. Pursuant to the December 2020 Board Remand, a VA medical opinion was obtained in May 2021. Initially, the Board notes that the VA examiner was instructed to review and discuss a February 2020 private medical opinion in providing the nexus opinion. Unfortunately, the May 2021 VA examiner indicated that she was unable to locate the February 2020 opinion and, as such, the opinion was not reviewed. The Board further observes that the examiner discussed the Veteran's complaints of joint pain and stiffness, as well as fatigue. The examiner concluded, "[t]here is no evidence that the Veteran's diffuse joint pain and stiffness, [and] chronic fatigue were due to an exposure in the Gulf War." The VA examiner discussed the potential relationship (or lack thereof) between Veteran's service-connected PTSD on his joint pain and fatigue symptoms. However, the examiner did not provide an opinion as to whether it is at least as likely as not that the Veteran's claimed joint pain/stiffness and fatigue are proximately caused or aggravated by his service-connected PTSD. As to the claimed GERD, the December 2020 Board Remand instructed the VA examiner to address whether the Veteran's symptoms were at least as likely as not due to or aggravated beyond the natural progression by his service-connected PTSD. However, the May 2021 VA examiner failed to address this question. Accordingly, the Board finds that the medical evidence of record remains inadequate to resolve the claims of entitlement to service connection for chronic joint pain and stiffness, chronic fatigue, and GERD. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(4); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made). As such, these matters must again be remanded to obtain a VA addendum opinion to address outstanding questions of nexus and aggravation. The matters are REMANDED for the following action: 1. Refer the VA claims file to a medical professional to obtain an opinion as to the claims of entitlement to increased disability ratings for idiopathic peripheral neuropathy of the right and left lower extremities prior to February 1, 2020. The examiner should review the Veteran's VA claims file and then provide a retrospective opinion concerning the severity of the symptoms associated with the Veteran's idiopathic peripheral neuropathy of the right and left lower extremities prior to February 1, 2020. In addressing the above, the VA examiner is asked to discuss how these findings were ascertained in retrospect, citing to specific evidence within the Veteran's file. While current findings are not at issue in the present case, if the VA examiner finds that a current physical examination or interview with the Veteran would assist him or her in providing the requested retrospective opinions, such should be scheduled, and the Veteran must be notified of the time and place to report. If the examiner determines that he/she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. 2. Refer the VA claims file to a clinician for an opinion on the etiology of the claimed chronic joint pain and stiffness, as well as chronic fatigue. The clinician is requested to review the claims file in its entirety including all service treatment records, VA, and private treatment records. Then, the clinician should respond to the following: (a) Does the Veteran have chronic joint pain and stiffness and/or chronic fatigue that are attributable to known clinical diagnoses? (b) Is it at least as likely as not (i.e., at least a 50 percent probability) that the Veteran's chronic joint pain and stiffness and/or chronic fatigue had its(their) onset during military service or is(are) causally related to such service, to include his service in Southwest Asia? (c) Alternatively, if the Veteran's claimed chronic joint pain and stiffness and/or chronic fatigue cannot be attributed to known clinical diagnoses, the examiner should indicate whether such symptomatology represents an objective indication of chronic disability resulting from undiagnosed illness related to the Veteran's Persian Gulf War service, or a medically unexplained chronic multisymptom illness defined by a cluster of signs or symptoms. If the Veteran's chronic joint pain and stiffness and chronic fatigue are found to represent an objective indication of chronic disability resulting from either an undiagnosed illness or a chronic multisymptom illness, the examiner should also describe the extent to which the illness has manifested. (d) Is it at least as likely as not that the claimed chronic joint pain and stiffness and chronic fatigue were caused by a service-connected disability, to specifically include PTSD? (e) Is it at least as likely as not that the Veteran's claimed chronic joint pain and stiffness and chronic fatigue are aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by a service-connected disability, to specifically include PTSD? If the Veteran's claimed chronic joint pain and stiffness and chronic fatigue are aggravated by a service-connected disability, the clinician should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. In rendering this opinion, the VA examiner MUST address the February 2020 private medical opinion from Dr. M.R., referenced above. The absence of evidence of treatment in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the clinician rejects the Veteran's reports of symptomatology, he or she should explain the basis for doing so. Should the clinician decide that a physical examination of the Veteran is required to address these questions, one should be scheduled. All examination findings/testing results (if any), along with complete, clearly-stated rationale for the conclusions reached, must be provided. 3. Refer the VA claims file to a clinician for an opinion on the etiology of the claimed GERD. The clinician is requested to review the claims file in its entirety including all service treatment records, VA, and private treatment records. Then, the clinician should respond to the following: (a) Is it at least as likely as not that the currently diagnosed GERD had its onset in service or is otherwise the result of a disease or injury in service to include the Veteran's service in Southwest Asia? (b) Is it at least as likely as not that the diagnosed GERD was caused by a service-connected disability, to specifically include PTSD? (c) Is it at least as likely as not that the Veteran's current GERD is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by a service-connected disability, to specifically include PTSD? If the Veteran's current GERD is aggravated by a service-connected disability, the clinician should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. In rendering this opinion, the VA examiner MUST address the February 2020 private medical opinion from Dr. M.R., referenced above. The absence of evidence of treatment in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the clinician rejects the Veteran's reports of symptomatology, he or she must explain the basis for doing so. Should the clinician decide that a physical examination of the Veteran is required to address these questions, one should be scheduled. All examination findings/testing results (if any), along with complete, clearly-stated rationale for the conclusions reached, must be provided. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. K. Buckley, 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.