Citation Nr: 22012224 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 20-06 769 DATE: March 2, 2022 ORDER Entitlement to service connection for an acquired psychiatric disability is denied. Entitlement to a 30 percent rating, but not higher, is granted for temporomandibular joint (TMJ) disorder of the right jaw as of April 8, 2019 (rather than as of May 9, 2019), subject to the statutes and regulations governing the payment of retroactive compensation. Entitlement to a 20 percent rating, but not higher, is granted from February 21, 2019 to July 26, 2021, for intervertebral disc syndrome (IVDS) with degenerative joint disease (DJD) of the lumbar spine, subject to the statutes and regulations governing the payment of retroactive compensation. Entitlement to a 20 percent rating, but not higher, is granted for associated radiculopathy of the left lower extremity involving the sciatic nerve from February 21, 2019 to July 26, 2021, subject to the statutes and regulations governing the payment of retroactive compensation. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. REMANDED Entitlement to an increased rating for contact dermatitis of the eyelids, evaluated as 0-percent disabling (noncompensable), is remanded. Entitlement to service connection for cervical strain (claimed as neck pain and as myalgia and myositis) is remanded. FINDINGS OF FACT 1. The most probative (meaning most competent and credible) evidence is against finding that the Veteran has an acquired psychiatric disability etiologically related or attributable to his military service. 2. It is just as likely as not that since April 8, 2019 he has had a maximum incisal opening of approximately 14-15mm because of the TMJ syndrome of his right jaw. 3. It is just as likely as not that he is entitled to a 20 percent rating, though not higher, for his IVDS with DJD from February 21, 2019 (one week prior to seeking treatment), but not earlier, to July 26, 2021, and not later. 4. It is just as likely as not he had moderate left lower extremity radiculopathy of the sciatic nerve from February 21, 2019 to July 26, 2021. 5. The most probative evidence is against finding that the Veteran's service-connected disabilities, singly or even in combination, preclude him from obtaining and maintaining substantially gainful (versus just marginal) employment consistent with his level of education and occupational history. CONCLUSIONS OF LAW 1. The criteria are not met for entitlement to service connection for an acquired psychiatric disability. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.384. 2. The criteria are met for a 30 percent rating, but not higher, from April 8, 2019 for TMJ of the right jaw; no other increased rating is warranted either prior to or since. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.150, Diagnostic Code (DC/Code) 9905. 3. The criteria are met for a 20 percent rating, but not higher for IVDS with DDD of the lumbar spine from February 21, 2019, but not earlier, to July 26, 2021, and not later. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242-5243. 4. The criteria are met for a 20 percent rating, and not higher, for the associated left lower extremity radiculopathy involving the sciatic nerve from February 21, 2019, but not earlier, to July 26, 2021, and not later. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124.a, DC 8520. 5. The criteria are not met for entitlement to a TDIU. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from August 2009 to March 2013. He testified in support of these claims during a February 2021 "virtual" teleconference hearing before the undersigned Veterans Law Judge of the Board. A transcript of the proceeding is of record. Service Connection In general, establishing service connection requires medical evidence or, in certain circumstances, lay evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a correlation ("nexus") between the disease or injury in service and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). 1. Entitlement to service connection for an acquired psychiatric disability The Veteran has received diagnoses of posttraumatic stress disorder (PTSD), major depressive disorder co-current with anxiety, and adjustment disorder. However, the Board finds that service connection is not warranted for any acquired psychiatric disability since there is not also the required attribution to his military service, i.e., the proverbial "nexus". The Board acknowledges the Veteran had complaints during his service of depression and difficulty with adjustment, but the most probative evidence indicates that the mental disorder diagnoses he since has received, instead, are unfortunately owing to things that have nothing to do with his military service. A March 2010 service treatment record (STR) shows the Veteran was in the process of a permanent change of station (PCS) to Korea. He reported that he had been depressed and had anhedonia. The assessment was adjustment disorder with depressed mood. A December 2012 STR recounts that the Veteran self-referred to behavioral health for stress-related issues mostly due to his work. The record notes that he reported, among other things, feeling irritable, having ethical problems with a noncommissioned officer (NCO), and feeling as if he was letting his fellow soldiers down by processing out of the Army. The assessment again was adjustment disorder. Subsequent screenings were negative for depression; the Veteran separated from service in March 2013. More than a year later, a September 2014 VA screening shows the Veteran reported that several days he had little interest or interest in doing things and several days of feeling down, depressed, or hopeless. A November 2014 record for initial history and physical purposes reflects that he did not feel anxious or depressed. In approximately July 2015, the Veteran's spouse had a stroke. March 2016 VA clinical records note complaints of depression but that he also conversely denied depression and anxiety. A November 2016 VA record notes that he is the caretaker of his wife. A December 2016/January 2017 DBQ list a diagnosis of adjustment disorder and notes the Veteran was then "currently having a bit of stress taking care of his wife who sustained a stroke last year." The examiner also considered the Veteran's complaints in service but ultimately determined that he was at the time of that mental status evaluation suffering from acute adjustment disorder due to his wife's health and their finances (i.e., Medicaid and food stamps). This clinician opined that it is less likely than not the Veteran has an acquired psychiatric disability, diagnosed as adjustment disorder, because of his service. The examiner explained that the Veteran was having stress taking care of his wife, and there were problems with Medicaid and food stamp benefits, which was additional stress. It also was noted that he had a son (approximately 7 years old) who had been diagnosed with attention deficit hyperactive disorder (ADHD) and opposition defiance disorder (ODD). This examiner clearly considered the Veteran's STRs, noting the complaints he also had during his service, but ultimately concluded those symptoms in service had resolved (i.e., he was no longer separated from his son due to the PCS, or working for the NCO that he had ethical problems with, or processing out of the military), and because of that his current mental impairment instead was attributed to the several unfortunate life or situational stressors that had befallen him in the years since his service. A January 2017 VA record shows the Veteran's wife continued to have residuals (sequelae) from her stroke including loss of speech and reading ability, and that their son, who had regressed in many ways, was displaying anger and disrespect. It also was noted the Veteran had been the full-time caregiver until then recently, which in turn had affected his sleep and diet. He resultantly inquired about counseling services when dealing with stressful events in his life. Subsequent records note various stressors including financial, health, and the continuing effects of the wife's stroke. When discussing the origins of his PTSD, it was noted that the precipitating stressor event was having witnessed his wife having a stroke, not instead anything that had occurred during his time in the military. A May 2018 private Neuropsychological evaluation report (Dr. S. Milne) shows diagnoses of major depressive disorder and generalized anxiety disorder. It notes, as history, that the Veteran's childhood was "rough", that his parents "beat him", that he was expelled from school in 9th grade, that he was in speech therapy in elementary school, and that he had behavioral problems while in school. It also notes conflict with his wife since her stroke due to behavior and personality changes. A February 2019 private report (LCSW M.B.) reflects that the Veteran sought counseling for "depression and adjustment to wife's disability in July 2015 and inability to obtain or maintain employment." When considering this collective body of evidence relevant to this claim, it shows the Veteran had adjustment issues while in service but that they resolved when his situation and circumstances changed. Post-service, he has dealt with a myriad of other significant issues ("stressors") most notably his son with ADHD and OCC and witnessing his mother (the Veteran's wife) have at least one seizure/stroke and acting out owing to the consequent cognitive and other impairment show now has. He also resultantly has been her caregiver since her stroke, and that, too, has had its own bevy of stressors. As well, he has had difficulties with finances and dealing with government programs such as food stamps and Medicaid. In short, while those life events certainly are unfortunate, they have nothing to do with the Veteran's time in the military. The Veteran's representative argued during the hearing before this Board that the examiner's opinion in the DBQ was inadequate because the examiner stated that the Veteran's symptoms in service had resolved in service (meaning they were acute and transitory rather than chronic (permanent)), and yet, according to the post-service records, the Veteran has an adjustment disorder. The Board, however, contrarily finds that the DBQ is indeed adequate since it readily acknowledged the symptoms the Veteran had in service. Moreover, while the Veteran has an adjustment disorder since service, it clearly has been attributed to factors unrelated to his military service and is not a continuation of the symptoms he had in service (would reasonably resolve when the precipitating factors were no longer present). Moreover, whether his post-service disability is labeled as acute or not acute, it has been related to post-service factors. The Veteran has not been shown to have the experience, training, or education necessary to give a probative opinion regarding the origins of his current disability, including in terms of whether related or attributable to anything that occurred during his time in the military. This determination is beyond his lay competence. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). See also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (indicating lay evidence must demonstrate some competence and affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). There is not a probative opinion (i.e., based on review of the pertinent facts and with adequate rationale) that it is as likely not that the Veteran has a current mental disorder causally related to his service or a service-connected disability. Since the most probative and therefore most persuasive, evidence is against his claim, not instead in approximate balance, the benefit of the doubt rule is not applicable. See Lynch v. McDonough, 999 F.3d 1391 (2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Increased Ratings Disability evaluations are determined by comparing a Veteran's present symptoms with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular DC, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R.§ 4.7. All reasonable doubt material to the determination is resolved in the Veteran's favor. Id. § 4.3. In general, it is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause functional loss, pain itself does not constitute functional loss. The Court in Mitchell explained that the evaluation of painful motion as limited motion only applies when limitation of motion is 0-percent disabling (noncompensable) under the applicable DC. The Court further explained that, although painful motion is entitled to a minimum 10 percent rating under Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991), when read together with DC 5003 concerning arthritis, it does not follow that the maximum rating is warranted under the applicable DC pertaining to range of motion simply because pain is present throughout the range of motion. Rather, the pain "must actually affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance' [under] 38 C.F.R. § 4.40 in order to constitute functional loss" warranting a higher rating. See id., at 43. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Nonetheless, even when the factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). According to 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Further, § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." See Correia v. McDonald, 28 Vet. App. 158 (2016). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the Veterans themselves, when a flare-up is not observable at the time of examination. In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. 2. Entitlement to an increased rating for the TMJ syndrome of the right jaw The Veteran's TMJ is rated as 10-percent disabling prior to May 9, 2019, and as 30-percent disabling since under DC 9905. A February 2017 rating decision granted service connection and assigned the initial 10 percent rating. In March 2017, the Veteran filed for reconsideration and another Regional Office (RO) decision consequently was issued in July 2017 that denied a rating higher than 10 percent. In July 2018, he filed a Notice of Disagreement (NOD) and ultimately appealed the decision to this Board. Thus, the rating period on appeal is from the date of service connection, which is November 18, 2016. However, the rating since has been increased to 30 percent as of May 9, 2019. So, this appeal now concerns whether an initial rating higher than 10 percent was warranted prior to that date and whether a rating higher than 30 percent has been warranted since. In other words, the Board must address the propriety of the "staging" of this rating. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (explaining that different ratings may be assigned at different times since the effective date of the award if there have been occasions when the disability has been more severe than at others). DC 9905 governs the evaluation of TMJ and provides as follows: (1) a 10 percent evaluation is warranted for lateral excursion range of motion limited to 0 to 4 millimeters; or interincisal range of motion limited to 30 to 34 millimeters of maximum unassisted vertical opening, without dietary restrictions to mechanically altered foods; (2) a 20 percent evaluation is warranted for interincisal range of motion limited to 30 to 34 millimeters of maximum unassisted vertical opening, without dietary restrictions to soft and semi-solid foods; or interincisal range of motion limited to 21 to 29 millimeters of maximum unassisted vertical opening, without dietary restrictions to mechanically altered foods; (3) a 30 percent evaluation is warranted for interincisal range of motion limited to 21 to 29 millimeters of maximum unassisted vertical opening, with dietary restrictions to mechanically altered foods; or interincisal range of motion limited to 11 to 20 millimeters of maximum unassisted vertical opening, without dietary restrictions to mechanically altered foods; (4) a 40 percent evaluation is warranted for interincisal range of motion limited to 11 to 20 millimeters of maximum unassisted vertical opening, with dietary restrictions to mechanically altered foods; or interincisal range of motion limited to 0 to 10 millimeters of maximum unassisted vertical opening, without dietary restrictions to mechanically altered foods; and (5) a 50 percent evaluation is warranted for interincisal range of motion limited to 0 to 10 millimeters of maximum unassisted vertical opening, with dietary restrictions to all mechanically altered foods. 38 C.F.R. § 4.150, DC 9905. Prior to May 9, 2019 (rated as 10-percent disabling) A December 2016 DBQ recounts the Veteran's reported problems of experiencing dull pain in the area of his right masseter muscle on exam, and at times he experiences crepitus but usually no pain associated with it. Flare-ups were noted to be pain when opening and soreness to touch in the area of right masseter muscle. Upon examination, he had right and left lateral excursion to 5 millimeters. He had an inter-incisal distance of 35 millimeters. There was no evidence of pain with chewing. His 10 percent rating adequately compensates him for his disability. His disability does not more nearly approximate the severity which would warrant a 20 percent rating because his interincisal was not limited to 30-34 mm or less, and he did not have dietary restrictions, and, notably, there was no evidence of pain with chewing. A June 2017 VA dentistry note reflects that the Veteran reported that his pain was getting worse but does not report findings which allow for evaluation. An April 8, 2019 VA dentistry note reflects a maximum incisal opening of 14 mm and notes "approximately 15 mm maximum incisal opening." This level of restriction warrants a 30 percent evaluation. Since May 9, 2019 (rated instead as 30-percent disabling) A May 2019 DBQ shows the Veteran reported pain, limited opening of his mouth, and consequent difficulty eating. For flare-ups, he reported tightness in his jaw with limited mobility; he also reported being unable to open or function the jaw. On examination, he had inter-incisal distance of 11-20 mm, and bilateral lateral excursion of 0-4 mm. He reported pain and difficulty chewing and sleeping on the right side, and pain on the left said. After repeated use, inter-incisal distance remained at 11-20 mm. He reported having lost 2-4 weeks over the last 12 months due to pain and restricted movement. These symptoms are adequately compensated by his 30 percent rating. A May 30, 2019 VA record notes a comfortable opening of 18 mm with no pain. It was noted that he demonstrated significant improvement in TMJ active range of motion and movement coordination. A higher 40 percent evaluation would only be warranted at that range of motion if he also had dietary restrictions to mechanically altered foods, which he does not have. The Veteran contended during his hearing before this Board that his staged rating (i.e., at least 30 percent) should have been assigned earlier and, if he had received an adequate examination in 2016, the severity of his TMJ would have been documented. But this is too speculative upon which to grant a higher rating. The Board sees that, in June 2017, he said his jaw pain was getting worse; this suggest it was not as severe in 2016 when his initial 10 percent rating took effect. Moreover, the record does not support that the 2016 examination was inadequate to rate the Veteran's disability. Finally, there was no evidence of pain on chewing in 2016, but there conversely was in 2019; again, this reflects a worsening of the disability in the intermim. The Board also sees the Veteran has reported private treatment, but he has not provided records showing that his disability meets the criteria for a higher evaluation. The duty to assist is not a one-way street. If he wishes help, he cannot passively wait for it in circumstances where he may or should have information that is essential in obtaining the putative evidence. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). While the Veteran is competent to report pain, he has not been shown to be competent to accurately assess the degree of motion/opening that he has due to his TMJ. The earliest that it can be factually ascertained that he met the requirement for a higher 30 percent rating is April 8, 2019 (rather than May 9, 2019). Moreover, his flare-ups have not been shown to be so frequent as to warrant a higher evaluation, as evidenced by his ability to eat a normal diet. It is possible that a particular piece of evidence demonstrates that the Veteran suffered from the symptoms of a disability or rating level earlier than the date of the examination, opinion, or diagnosis. See Delisio v. Shinseki, 25 Vet. App. 45, 56 (2011) (holding that "entitlement to benefits for a disability or disease does ot arise with a medical diagnosis of the condition, but with the manifestation of the condition and the filing of a claim for benefits for the condition" (citing 38 U.S.C. § 5110(a)); Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010) (holding that "it is the information in a medical opinion, and not the date the medical opinion was provided that is relevant when assigning an effective date"). It is for this reason that the Board has granted the higher 30 percent rating as of April 8, 2019 (rather than as of May 9, 2019, so as of a slightly earlier effective date). That said, there is no other probative evidence providing the exact onset of his current level of disability with any certainty despite a complaint of worsening symptoms. The Board also finds that the established schedular criteria are adequate to compensate the Veteran for the severity and symptoms of his disability. Notably, he is already in receipt of service connection for migraines. Moreover, he does not have indicia of an exceptional or unusual disability picture, such as marked interference with his employment or frequent periods of hospitalization owing to his TMJ. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Although he reported missing 2-4 weeks over a 12-month period, he has not provided supporting evidence of this (e.g., sick leave records), and, regardless, at most, this would equate to missing less than 10 percent of employment during a given year. His disability rating, itself, is recognition that industrial capabilities are impaired. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 3. Entitlement to higher "staged" ratings for the IVDS with DJD of the lumbar spine The rating for this disability also has been "staged"; it was rated as 10-percent disabling from November 18, 2016 to May 10, 2019, as 20-percent disabling from May 10, 2019 to July 26, 2021, and has been rated as 10-percent disabling since under hyphenated DC 5242-5243. A hyphenated DC is used when the rating under one DC requires use of an additional DC to explain the basis for the evaluation. See 38 C.F.R. § 4.27. The Veteran's "staged" ratings are part of his initial rating because they stem from his NOD with a February 2017 rating decision that granted service connection and assigned the initial 10 percent rating. Prior to issuance of a Statement of the Case (SOC) in January 2020, he filed for an increased rating; however, the initial rating decision had not at that point become a final and binding determination. During the pendency of this appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select DCs "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. Id. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021 onward. The criteria that are more favorable to him will be applied again, however, only as of February 7, 2021 if the revised criteria. See also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). DC 5243 provides that IVDS is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. DC 5243 only had a minor change under the February 7, 2021 regulatory amendments, that being clarification that DC 5243 now is only for application when there is disc herniation with compression and/or irritation of the adjacent nerve root. The Formula for Rating IVDS Based on Incapacitating Episodes and the General Formula for Disease and Injuries of the Spine did not change. The Formula for Rating IVDS Based on Incapacitating Episodes provides that a 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Note (1) to DC 5243 explains that, for purposes of ratings under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. And a 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine (meaning when additionally considering the adjacent cervical segment). 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note (5). Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note (1). The Veteran already has established service connection additionally for radiculopathy of his lower left extremity since associated with his low back disability, and this additional impairment is rated separately, as required, which will be discussed later in this decision. November 18, 2016 May 10, 2019 (rated as 10-percent disabling) The Veteran would be entitled to a higher 20 percent rating if he had forward flexion of his thoracolumbar spine to greater than 30 degrees but not to greater than 60 degrees or the combined range of motion of his thoracolumbar spine not greater than 120 degrees. A December 2016 DBQ shows the Veteran reported that, over the past four years, his back pain had become constant and sharp and was worse with repetitive movements and weightlifting. He also reported shooting pain down his left lower extremity and intermittent numbness/tingling in his left great toe. On examination, all initial ranges of motion were normal; no pain was noted upon examination. On repetitive use testing, he continued to have full range of motion. He also had full muscle strength and normal reflexes. It was noted he had mild intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness of his left lower extremity, but no other radiculopathy symptoms. The left sciatic nerve was involved, but not the right side. The examiner surmised the left nerve involvement was mild. The examiner found no evidence of pain when the joints were used in non-weight bearing, normal passive range of motion, and no pain on passive range of motion testing. The Veteran did not report flare-ups. That DBQ does not reflect that a rating greater than 10 percent is warranted. A February 2017 VA physical therapy record shows the Veteran was seen for chronic low and mid-thoracic left side back pain. He reported occasional radiating symptoms down his left lower extremity. He reported worsening symptoms with "a lot of activities", but that he was still able to perform all activities. On examination, he had full active range of motion of his lumbar spine. A February 28, 2019 record relates the Veteran reported one week of progressive left leg weakness and left-sided back pain. The assessment was mild degenerative disease of the lumbar spine. A subsequent record from just a few months later shows he had reduced range of motion; thus, the Board can reasonably find that, as of February 21, 2019, a higher 20 percent rating is warranted for his low back disability. February 21, 2019 July 26, 2021 (now rated as 20-percent disabling) A May 10, 2019 DBQ reflects that the Veteran had forward flexion to 70 degrees, extension to 15 degrees, bilateral lateral flexion to 20 degrees, and bilateral lateral rotation to 25 degrees. After repetitive use testing, his forward flexion was decreased to 55 degrees, and his extension decreased to 10 degrees. His other degrees remained the same. He reported having had a flare up in February 2019 when he went to a private emergency room; but the DBQ examiner could not assess the severity of flare-ups. It was noted that he had muscle spasms which resulted in abnormal gait or spine contour. It was also noted that he had bed rest having a total duration of at least one week but less than two weeks in the past 12 months; this would warrant a 10 percent under the rating formula for IVDS with incapacitating episodes, but he is granted a higher, 20 percent, rating under the General Rating Formula for Diseases and Injuries of the Spine. He would be entitled to a higher, 40 percent rating for the spine, if he had forward flexion of the thoracolumbar spine to 30 degrees or less; however, he had far greater forward flexion of 70 degrees, and even after repetitive use, it still exceeded 30 degrees. Regarding radiculopathy, the Veteran was observed to have moderate intermittent left lower extremity pain, mild paresthesias and/or dysesthesia, and mild numbness. He had negative straight leg rating test results, normal reflexes, and normal sensation to light touch except in his left lower ankle, which was decreased. The right lower extremity was unaffected. The examiner found that the overall level of severity was moderate left lower extremity radiculopathy of the sciatic nerve. July 26, 2021 the present (rated as 10-percent disabling) A July 2021 DBQ reflects that Veteran had forward flexion to 70 degrees, extension to 15 degrees, bilateral lateral flexion to 30 degrees, and bilateral lateral rotation to 30 degrees. His combined range of motion was 205 degrees. After repetitive use testing, there was no additional loss of range of motion. He had IVDS but had not had any incapacitating episodes as defined by VA regulation. He did not report flare-ups. The DBQ supports that a 10 percent rating adequately compensates him for the extent of his symptoms and consequent impairment. Conclusion and neurologic findings The Veteran's evaluations adequately compensate him for his spine symptoms and the impairment resulting from them. While he has reported pain, he retains significant range of motion, as evidenced by the above-noted findings. Moreover, his low back motion is not limited to a degree or an extent to consider it akin to ankylosis meaning the "functional equivalent", such as during times when his symptoms are most prevalent ("flare ups") or during prolonged or repeated use of his low back. See Chavis v. McDonough, 34 Vet. App. 1 (2021). There is neither probative lay evidence nor clinical findings tending to show that his disability rises to the level of ankylosis or something tantamount to it. The Veteran already has this minimally required 10 percent rating to compensate him for the limitation of motion he has owing to his low back disability, including because of his pain. The evidence on the whole does not tend to support the notion that he additionally has bowel or bladder impairment (see DBQs). The Board has considered evidence of flare-ups of his low back, but this, too, does not provide grounds for any higher rating. The 2016 and 2021 DBQs reflect that he did not report flare-ups, and the intervening 2019 DBQ indicates he only reported the one flare-up in February 2019. When taken together, his single flare up over a five-year period, which was described as "moderately-severe" and lasted one to two weeks, does not rise to the level warranting an increased rating including during that specific timeframe. As for the associated radiculopathy, the Veteran is in receipt of service connection for left lower extremity radiculopathy under DC 8520 for the impairment of his sciatic nerve, evaluated as 10-percent disabling from November 18, 2016 to May 10, 2019, as 20-percent disabling from May 10, 2019 to July 26, 2021, and again as 10-percent disabling since. He also has a separate rating under DC 8526 of 10 percent for femoral involvement effective from June 18, 2021. According to DC 8520, mild incomplete paralysis of the sciatic nerve is rated as 10-percent disabling. Moderate incomplete paralysis is rated as 20-percent disabling. Moderately severe incomplete paralysis is rated as 40-percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60-percent disabling. Complete paralysis, when the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost, is rated as 80-percent disabling. According to DC 8526, mild incomplete paralysis of the femoral nerve is rated as 10-percent disabling. Moderate incomplete paralysis is rated as 20-percent disabling. Severe incomplete paralysis is rated as 30-percent disabling. Complete paralysis of the quadriceps extensor muscles is rated as 40-percent disabling. These descriptive terms "mild", "moderate", "moderately severe", and "severe" are not specifically defined in the Rating Schedule. But regulations provide that ratings for peripheral neurological disorders are to be assigned based on the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the "mild," or at most, the "moderate" degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at Diseases of the Peripheral Nerves. The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. Moreover, physical manifestations do not automatically require a rating greater than moderate incomplete paralysis. Rather, wholly sensory impairment may only be rated commensurate with mild or moderate impairment. Miller v. Shulkin, 28 Vet. App. 376 (2017). Examples of physical manifestations include, but are not limited to, muscle weakness, muscle atrophy and diminished or absent reflexes. Examples of sensory manifestations include, but are not limited to, pain (constant, intermittent, or dull), numbness, paresthesias (abnormal touch sensation, burning or prickling, often in the absence of external stimulus), and dysesthesias (distortion of any sense, or unpleasant abnormal sensation produced by normal stimuli). When adjudicating claims not involving wholly sensory impairment (i.e., there is a mix of physical and sensory impairments, such as decreased reflexes and numbness), a rating of mild incomplete paralysis is warranted when there are less persistent sensory deficits that affect small areas or for very minimal reflex or muscle strength impairment. A rating of moderate incomplete paralysis may be warranted when there are combinations of significant sensory changes and mild or slight muscle or reflex impairment or muscle and/or reflex impairment that has been noted by the examiner to be moderate in nature. The evidence as noted above, is against increased ratings, or earlier effective dates for the ratings provided. The December 2016 DBQ noted full muscle strength, and normal reflexes, and only mild intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness of the left lower extremity. A May 2019 DBQ reflects moderate intermittent left lower extremity pain, mild paresthesias and/or dysesthesia, and mild numbness. He also had normal reflexes, and normal sensation to light touch with the exception of the left lower ankle which was decreased. However, as the Board has acknowledged a worsening of symptoms on February 21, 2019, the Board will resolve reasonable doubt in the Veteran's favor and grant a 20 percent rating for moderate sciatic incomplete paralysis on that same date. The evidence does not reflect more severe impairment. A July 2021 DBQ reflects mild constant pain, mild paresthesias and/or dysesthesias, and mild numbness of the lower extremity. He had normal reflexes. Concerning sensation, he had decreased, but not absent, sensation to light touch. Again, the right lower extremity was not affected. Based on the results, it can reasonably be found that his symptoms equate with a mild disability. The Board is mindful that his symptoms seem more severe than when examined in 2019, however, he retained full muscle strength and full reflexes; thus, his symptoms were wholly sensory, albeit with two different nerves affected. When the involvement is wholly sensory, the rating is for the "mild" or at most the "moderate" degree. The Board finds that his sensory findings, which show he still retained some sensation, and only had mild numbness and mild constant pain, and mild paresthesias and/or dysesthesias are adequately compensated by 10 percent ratings for mild incomplete paralysis of the sciatic and femoral nerves. The Board also finds that the established schedular criteria are adequate to compensate the Veteran for the severity and symptoms of his disability. Moreover, he does not have indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). 4. Entitlement to a TDIU As already mentioned, generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 C.F.R. §§ 4.1, 4.15. In other words, the disability rating, itself, is recognition that industrial capabilities are impaired. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Therefore, impairment above and beyond that is required for a TDIU claim to prevail although total or 100-percent unemployability is not required since the use of the word "substantially" (in substantially gainful employment) suggests an intent to impart flexibility into the determination of the Veteran's overall employability. See Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). A TDIU may be assigned where the schedular rating is less than total when it is found that a Veteran is unable to obtain or follow a substantially gainful occupation as a result of service-connected disabilities and has a single service-connected disability ratable at 60 percent or more or two or more service-connected disabilities when one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability or disabilities to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following disabilities will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. See 38 C.F.R. § 4.16(a). When a Veteran fails to meet the applicable percentage standards set forth in § 4.16(a), the Board should consider whether to refer the claim to the Director of the Compensation Service for extra-schedular TDIU consideration under the special provisions of § 4.16(b). But, at most, the Board can consider whether this referral is warranted, not instead grant a TDIU on an extra-schedular basis in the first instance. See Barringer v. Peake, 22 Vet. App. 242 (2008). The Veteran is in receipt of service connection for TMJ of his right jaw, migraines, tinnitus, right foot plantar fasciitis, radiculopathy of the femoral nerve, radiculopathy of the sciatic nerve, IVDS with DJD of the lumbar spine, left foot hallux valgus, contact dermatitis of the eyelids, and gastroesophageal reflux disease (GERD), for a combined 30 percent rating from November 18, 2016 to May 9, 2019, 50 percent from May 9, 2019 to May 10, 2019, 60 percent from May 10, 2019 to June 18, 2021, 80 percent from June 18, 2021 to July 26, 2021, and 70 percent since. However, as earlier explained, the Board has determined that he is entitled to a 30 percent rating for his TMJ from April 8, 2019 (rather than May 9, 2019), and 20 percent ratings for his low back disability and associated sciatic nerve radiculopathy of his left lower extremity from February 21, 2019 to July 26, 2021. The ratings for the Veteran's service-connected disabilities do not meet the rating criteria for schedular consideration of a TDIU for most of the rating period on appeal (i.e., prior to June 18, 2021); regardless, the Board finds that a TDIU is not warranted, even an extra-schedular referral. Prior to June 18, 2021, his service-connected disabilities are his right jaw TMJ, tinnitus, left lower extremity radiculopathy, IVDS with DJD of the lumbar spine, left foot hallux valgus, and contact dermatitis. The Veteran has an associate's (AA) degree and was last employed in some capacity in 2018. He has employment experience as a parts manager and as a construction supervisor, basically directing the workers on what was needed to be completed (see Board hearing transcript at page 17). The Veteran testified during his hearing before this Board that he is unemployable because of his service-connected disabilities in combination with the ones that he is trying to establish service connection for (see Board hearing transcript, page19). An April 2017 VA Counseling Record (VA Form 28-1902b) recounts that the Veteran's wife had a stroke in 2015 that consumed "a lot of his time". The report also notes that his service-connected and non-service-connected disabilities would impose restrictions in positions that are physically demanding since that may irritate or aggravate his service-connected disabilities. This report further notes that he would be best served in a sedentary job with accommodations. Social Security Administration (SSA) records dated in 2019 show the Veteran has depression/bipolar disorder and a secondary diagnosis of somatic symptom disorder, but that he is not too disabled to work. He had filed for SSA benefits due to "severe depression, severe anxiety, TMJ, back injury, leg injury, sleep condition, persecution for opting for state medical marijuana prog[ram]." He alleged an inability to work as of July 1, 2016. The examining clinician (Dr. J. Cordero) found that the Veteran has no limitations on ability to stand, walk, bend or stoop, reach, handle, lift, carry, see, hear or with memory or understanding. It also was noted that he ambulates without difficulty and without any assistive device. A May 2019 DBQ for TDIU purposes indicates the Veteran is able to do sedentary work allowing him to stand/walk around for brief periods of time as needed, but that his low back disability and associated radiculopathy make bending, prolonged sitting and standing, and heavy lifting/strenuous activity difficult. The Court has held that the central inquiry in determining whether a Veteran is entitled to a TDIU is whether service-connected disabilities, alone, are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). The test of individual unemployability is whether the Veteran, because of service-connected disabilities, alone, is unable to secure or follow any form of substantially gainful occupation that is consistent with her education and occupational experience. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. In Ray v. Wilkie, 31 Vet. App. 58 (2019), the U. S. Court of Appeals for Veterans Claims (Veterans Court/CAVC) held that "substantially gainful employment," in the TDIU context, contains economic and noneconomic components; the economic component means "an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person," while the noneconomic component requires consideration of a Veteran's ability to secure or follow that type of employment. The Court also provided guidance as to the meaning of a Veteran's ability to "secure and follow" such employment, noting that attention must be given to: the Veteran's occupational history, education, skill and training; whether the Veteran has the physical ability to perform occupational activities; and whether the Veteran has the mental ability to perform occupational activities. On November 19, 2021, the Court issued a precedential panel decision in Snider v. McDonough, No. 19-6707, vacating and remanding a Board decision that had denied an extra-schedular TDIU under 38C.F.R. §4.16(b) without first considering whether a referral to the Director of the Compensation Service was warranted under the standard set forth in Ray v. Wilkie, 31 Vet. App. 58, 66 (2019). When denying an extra-schedular TDIU referral to the Director under § 4.16(b), the Board must make two determinations in its decision: (1) that a referral for extra-schedular TDIU is not warranted under the "reasonable possibility" standard set forth in Ray, and (2) that TDIU benefits are not warranted because the Veteran is not unemployable due to service-connected disabilities "Substantially gainful employment" is employment" that is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16(a). That said, the mere fact that a Veteran is unemployed or has difficulty obtaining employment is not enough since, to reiterate, a disability rating, itself, is recognition there is impairment of earning capacity. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013), the Federal Circuit Court held that, when a Veteran is claiming entitlement to a TDIU based on the combined effect of multiple service-connected disabilities, VA's duty to assist "does not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities." See also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). Although VA must give full consideration, per 38 C.F.R. § 4.15, to "the effect of combinations of disability," VA regulations place responsibility for the ultimate TDIU determination on VA adjudicators, not a medical examiner's opinion. The ultimate issue of whether TDIU should be awarded is not a medical issue, but rather is a determination for the VA adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev'd on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Here, with all this in mind, the Board finds that the Veteran is not entitled to a TDIU. The Board has considered his employment history and his education, but the most probative evidence is against finding that his service-connected disabilities, singly or in combination, preclude substantially gainful employment. The 2021 DBQ notes that his low back disability interferes with repetitive bending or twisting for longer than 30 minutes or lifting weight over 20 lbs. The December 2016 DBQ found his service-connected disabilities had no impact on his occupation. The 2016 DBQ notes he cannot run due to his foot disability, and the 2019 DBQ notes that bending, prolonged standing and sitting, and heavy lifting/strenuous activity may be difficult. His migraines can also be expected to interfere with some functions, but the duration of his headache pain is typically less than a day, and he has reported only missing 1-2 weeks in a 12-month period (see, e.g., December 2021 DBQ). The Veteran's work experience and level of education are factors in determining his employability, and there are jobs that he realistically still can do even with his work experience and level of education and where he would need to be able to sit or stand at intervals. As he has explained, he had been a construction supervisor where he was "pretty much directing the workers on what needed to be completed". As a supervisor, he can reasonably be expected to be able to sit and stand when needed. In addition, his limitations would not preclude him from landscaping (using a riding mower), a short-distance truck driver, or a bus driver, all of which would allow for him to sit but get up at intervals. He could perform a job such as a receptionist, cashier, telephone marketer, bank teller, or customer service representative, all of which can be done sitting down, do not require heavy lifting or extensive bending, and allow him to stand when needed, especially with use of cordless phones. The Board also notes that he is the primary caretaker for his disabled wife and for his son, and in those capacities shops for groceries and does the chores and prepares the meals, himself, thus evidencing he has sufficient ability to perform tasks on a substantial level. Indeed, even the Veteran, himself, has conceded that it is a combination of his service-connected and nonservice-connected disabilities that renders him unemployable, and his SSA records, while not binding on this Board, show that he is not too disabled to still work in a substantially gainful versus just marginal job. While as mentioned SSA determinations are not binding on this Board, since the two Federal agencies have different eligibility requirements, they are, however, relevant. See Martin v. Brown, 4 Vet. App. 136, 140 (1993) (while an SSA decision is not controlling for purposes of VA adjudication, it is "pertinent" to a Veteran's VA claim); see also Collier v. Derwinski, 1 Vet. App. 413, 417 (1991). The record, on the whole, indicates that referral of this claim to the Director under § 4.16(b) is not required because there is not a "reasonable possibility" that his service-connected disabilities, alone, preclude substantially gainful employment. Moreover, these service-connected disabilities do not preclude substantially gainful employment. And since the most probative and therefore most persuasive, evidence is against this claim, not instead in "approximate" (nearly equal) balance, the benefit of the doubt rule is not applicable. See Lynch v. McDonough, 999 F.3d 1391 (2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). REASONS FOR REMAND 5. Entitlement to an increased rating for contact dermatitis of the eyelids, evaluated as 0-percent disabling (noncompensable) The Veteran's disability is rated under DC 7806 as noncompensable (0 percent). He has been afforded examinations in March 2017 and December 2019. The DBQs are against finding that at least five percent of the entire body or exposed areas is affected. However, the Veteran testified at the 2021 Board hearing that he has been told that five percent of his body is affected. He further testified that his skin disability has been worse than when examined and has spread from his face to his chest. Thus, the Board will afford him another examination. He also has asserted that he would like to submit photographs of flare-ups. The Veteran's STRs records reflect that in 2012, he had hydraulic acid splashed in his eyes, which were flushed, and then medically examined. At a December 2016 examination for his eyes, he asserted that he experiences rash and itchiness on his bilateral lower eyelids intermittently since the incident. Thus, he was granted service connection for contact dermatitis of the eyelids. Additional clinical records reflect that the Veteran has been diagnosed with seborrheic dermatitis, that he has a skin rash which is "just photosensitivity", and that his rash has been on the nasolabial folds, eyebrows, ears, and lip (see, e.g., November 2014, June 2019, September 2020, and December 2020 VA clinical records). The Veteran is only in receipt of service connection for contact dermatitis of the eyelids. A clinical opinion as to whether the Veteran's current diagnosis of seborrheic dermatitis is part of, or related to, his service-connected disability may be useful. Essentially, would the contact dermatitis have spread to his face or chest, would it first manifest sometime after 2012 as it was not noted in service, and is it likely as not caused by exposure to hydraulic fluid which splashed in his eyes/face in 2012. 6. Entitlement to service connection for cervical strain (claimed as neck pain and as myalgia and myositis) The earliest post service clinical complaint of the neck/cervical spine is more than three years after separation from service. A November 2014 VA record to establish medical care reflects that the Veteran complained of bilateral leg and foot pain, but he denied neck pain or stiffness. Two years later, in November 2016, he filed a claim for service connection for neck pain. The claims file includes a December 2016 DBQ in which the Veteran recounted that he was unable to recall an onset of cervical spine symptoms, but noted that "since a few weeks ago", he has been experiencing intermittent right posterior neck tightness and aching pain. A corresponding February 2017 DBQ includes the clinician's opinion that it is less likely as not that the Veteran has a cervical spine disability due to service. The clinician's opinion was, in part, as follows: Service records do not document a chronic on-going treatment or condition for lumbar radiculopathy or cervical strain. . . . He was seen briefly for neck pain in relation to viral illness and once for myositis associated with an infection and TMJ, but these are distinct and separate diagnoses from cervical strain. The Board notes, however, that an April 12, 2011 STR reflects that the Veteran had a neck strain. He reported neck stiffness since March after moving furniture. (The Board notes that the STR notes March 2010; however, the Board finds that this is a typographical error and should be March 2011. This is evident by the lack of STRs noting a year of ongoing pain, and an April 1, 2011 STR which reflects that the Veteran had been moving heavy boxes and furniture the prior weekend (i.e., March 2011) and now had body aches.) Thus, the Veteran had approximately two weeks of neck pain after moving things. A February 2012 STR notes that the Veteran was seen for muscle spasms in the neck. A March 2012 record notes that he had taking a PT test on Friday and had neck and back pain "this weekend" for which he took Flexeril with improvement of symptoms; he was assessed with muscle strains. The Board resultantly finds that a supplemental opinion should be obtained that considers the above noted complaints Accordingly, these remaining claims are REMANDED for the following action: 1. Ask the Veteran to submit photographs of his dermatitis during a flare-up. These pictures are needed to show how bad this skin disorder may be during times other than when he is being evaluated for it, so outside the confines of a VA compensation examination when he might not be having a flare up. 2. Schedule him for an examination, if reasonably possible during an "active" rather than dormant stage of his dermatitis, to reassess the severity of it. The clinician should opine on whether it is as likely as not (50 percent or greater probability) the Veteran's seborrheic dermatitis is part and parcel of, or related to, his service-connected contact dermatitis of the eyelids (i.e., consider whether the contact dermatitis has spread to his face or chest, would it first manifest sometime after 2012 as it was not noted during his service, and is it as likely as not caused by exposure to hydraulic fluid that splashed on his face in 2012?). To assist in making this determination, the examining clinician should consider the pertinent evidence of record including especially: the August 2012 STR and the post-service records noting seborrheic dermatitis, a skin rash that is "just photosensitivity", and that his rash has been on the nasolabial folds, eyebrows, ears, and lip (see, e.g., November 2014, June 2019, September 2020, and December 2020 VA clinical records). In responding, whether favorably or unfavorably, the examiner must provide rationale as to why, or why not, the seborrheic dermatitis is or is not related to the contact dermatitis. 3. Also obtain a supplemental opinion to the December 2016/February 2017 DBQs regarding the additionally claimed cervical spine disability. In rendering an opinion on whether it is as likely as not (50 percent or greater probability) the Veteran has a current cervical spine disability related to his service, the examiner should consider the pertinent evidence of record including especially: a) an April 1, 2011 STR noting the Veteran had been moving heavy boxes and would be in the future and the weekend prior had body aches; b) an April 12, 2011 STR showing he had a neck strain from moving items; c) a February 2012 STR showing he was seen for muscle spasms in his neck; d) a March 2012 record indicating he had done a PT test on Friday and had neck and back pain "this weekend" for which he took Flexeril with improvement of symptoms; the assessment was muscle strain. In responding, whether favorably or unfavorably, the examiner must provide rationale preferably citing to findings or other evidence of record supporting conclusions and/or accepted medical authority. KEITH W. ALLEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Wishard 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.