Citation Nr: 22017487 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 17-28 978 DATE: March 25, 2022 ORDER Entitlement to a disability rating in excess of 30 percent before May 2, 2017, and in excess of 50 percent thereafter, for posttraumatic stress disorder (PTSD) is denied. Entitlement to an increased rating of 10 percent, but not more, from April 4, 2014, to before March 28, 2017, is granted. Entitlement to disability ratings in excess of 10 percent before June 24, 2021, and in excess of 20 percent, thereafter, is denied. REMANDED Entitlement to service connection for a throat condition is remanded. Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for a skin disability, to include a fungal infection and contact dermatitis, is remanded. FINDINGS OF FACT 1. Before May 2, 2017, the severity, frequency, and duration of the Veteran's PTSD symptoms did not more closely approximate occupational and social impairment with reduced reliability and productivity. 2. From May 2, 2017, onward, the severity, frequency, and duration of the Veteran's PTSD symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 3. From April 4, 2014, to before June 24, 2021, the Veteran's lumbosacral strain with mild degenerative changes was manifest by no worse than forward flexion to 61 degrees and combined range of motion of 121 degrees with localized tenderness that did not result in abnormal gait or spinal contour. 4. From June 24, 2021, onward, the Veteran's lumbosacral strain with mild degenerative changes was manifest by no worse than forward flexion to 31 degrees without ankylosis. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for PTSD before May 2, 2017, or for 50 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a rating of 10 percent, but not more, for lumbosacral strain with mild degenerative changes, have been met from April 4, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 3. The criteria for a rating in excess of 20 percent for lumbosacral strain with mild degenerative changes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from September 1997 to November 2001 and from May 2010 to May 2012, as well as periods of active duty for training. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of August 2014, September 2016, and June 2018, by the Department of Veterans Affairs (VA); this case is in VA's legacy appeals system. In September 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. Increased Ratings 1. Increased Ratings for PTSD The Veteran contends that he is entitled to higher ratings for his PTSD because his current ratings of 30 percent before May 2, 2017, and 50 percent thereafter do not fully recognize and compensate for the severity of his PTSD symptoms. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 50 percent or higher before May 2, 2017, or for a disability rating of 70 percent or higher thereafter. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 50 percent or higher before May 2, 2017, or for a disability rating of 70 percent or higher thereafter. Before May 2, 2017, the Veteran's symptoms more closely approximated the symptoms associated with a 30 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 30 percent rating. Beginning May 2, 2017, the Veteran's symptoms more closely approximated the symptoms associated with a 50 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. Before May 2, 2017 Before May 2, 2017, VA and private treatment records, the January 2014 and August VA examination, and lay statements from the Veteran and his family show that the Veteran's PTSD was manifested by symptoms associated with a 30 percent rating including anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, and mild memory loss. It also manifested as disturbances of motivation and mood, which is consistent with a 50 percent rating. Finally, he had symptoms that are not listed with a specific rating, such as recurrent intrusive or distressing thoughts or memories of his stressor, efforts to avoid these intrusive thoughts or memories and external reminders of these thoughts or memories, persistent and exaggerated negative beliefs, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, hypervigilance, an exaggerated startle response, and feeling persistently ambivalent. The Board finds the severity, frequency, and duration of the Veteran's unlisted symptoms more closely approximate the symptoms contemplated by a 30 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 50 percent rating. See 38 C.F.R. § 4.126. Recurrent intrusive or distressing thoughts or memories, as well as efforts to avoid them and avoid external reminders of them, hypervigilance, and exaggerated startle response are similar to the listed symptoms of anxiety and panic attacks. Persistent feelings of ambivalence, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, and persistent and exaggerated negative beliefs are similar to the listed symptom of depressed mood. These listed symptoms, similar or equivalent to the Veteran's unlisted symptoms, are contemplated by the assigned 30 percent rating. The Board also finds that before May 2, 2017, the level of impairment caused by the Veteran's symptoms more closely approximate the level associated with a 30 percent rating. The Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). While there were lay statements indicating his symptoms restricted his social interactions and negatively impacted his marriage and family relationships, the Veteran remained married and lived with his wife and two minor children for this entire period. He also maintained consistent full-time employment without noted reprimands or reduction in productivity. Mental status examinations in treatment records indicate that the Veteran was well groomed with fair eye contact, with normal rate and tone of speech, fine mood with congruent affect, goal directed and reality-based thought content and processes, and fair insight and judgment. He denied suicidal or homicidal ideation and any perceptual disturbances. Lay statements provided by his spouse and parents were consistent with the symptoms noted in the treatment notes and VA examination. While the Veteran did experience symptoms contemplated by a 50 percent rating disturbances of motivation and moodthe evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 30 percent rating. May 2, 2017, onward Beginning May 2, 2017, VA and private treatment records, the August 2017 and July 2021 VA examinations, and the Veteran's lay statements show that the Veteran's PTSD was manifested by symptoms associated with a 50 percent rating including anxiety, suspiciousness, chronic sleep impairment, mild memory loss (including forgetting directions, names, and recent events), difficulty in establishing and maintaining effective work and social relationships, and disturbances of motivation and mood. It also manifested as difficulty in adapting to stressful circumstances, including his work, which is consistent with a 70 percent rating. Finally, he had symptoms that are not listed with a specific rating, such as recurrent intrusive or distressing thoughts or memories of his stressor, intense or prolonged psychological distress at exposure to cues that symbolize or resemble an aspect of his stressor, efforts to avoid these intrusive thoughts or memories and external reminders of these thoughts or memories, dissociative reactions (e.g. flashbacks), persistent and exaggerated negative beliefs, distorted cognitions about the cause or consequences of his stressor, and negative emotional state, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, irritable behavior and angry outbursts, problems with concentration, hypervigilance, and an exaggerated startle response. The Board finds the severity, frequency, and duration of the Veteran's unlisted symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. See 38 C.F.R. § 4.126. Recurrent intrusive or distressing thoughts or memories, intense or prolonged psychological distress at exposure to cues, as well as efforts to avoid them and avoid external reminders of them, dissociative reactions, hypervigilance, and exaggerated startle response are similar to the listed symptoms of anxiety and panic attacks. Markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, and persistent and exaggerated negative beliefs, distorted cognitions about the cause or consequences of his stressor, and negative emotional state, are similar to the listed symptoms of depressed mood and disturbances of motivation and mood. Problems with concentration is similar to the memory loss symptoms contemplated by both 30 and 50 percent rating criteria. Irritable behavior with angry outbursts is similar to impaired judgement. With the exception of impaired judgment, these listed symptoms, similar or equivalent to the Veteran's unlisted symptoms, are contemplated by the assigned 50 percent rating. The Board also finds the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 50 percent rating. The Veteran experienced occupational and social impairment with reduced reliability and productivity. Mental status examinations in VA and private treatment records and the August 2017 and July 2021 VA examinations indicate that the Veteran was appropriately dressed and groomed with normal rate and tone of speech. His affect was euthymic, and his thinking was goal oriented. His insight, judgment, and impulse control were fair. He consistently denied suicidal or homicidal ideation and audio or visual hallucinations. VA mental health treatment records from May 2, 2017, and March 1, 2019, show the Veteran reported throwing himself into work so he wouldn't have time to think about anything else. During his August 2017 VA examination the Veteran reported working as a construction division manager for a cell tower company for the past five years, with a promotion after three years on the job. He reported no problems, write ups, or demotions. During the July 2021 VA examination, the Veteran reported that at some point in 2017 he was promoted to a managerial position but after one year he and the company owner determined he was not suitable for this position because of his irritability with coworkers and supervisees. In that year six of the Veteran's nine supervisees resigned, compared to typical staff turnover of two per year. The Veteran returned to his previous position which involved more manual labor and only supervising one other employee. While the Veteran did experience symptoms contemplated by a 70 percent ratingdifficulty in adapting to stressful circumstances and irritable behaviour with angry outburststhe evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 50 percent rating. Irritable behavior can range from verbal response to physical assault, and there is no evidence the Veteran's irritability ever rose to the level of physical response. The Veteran's irritable behavior showed he was not a good fit for a managerial position but did not prevent him from maintaining full time employment for at least nine years with the same company. Given that the two symptoms consistent with a 70 percent rating were of relatively low severity and the majority of his symptoms were consistent with a 50 percent rating, and the Veteran lived with his wife and two children while maintaining full time employment for this period, the Board finds that he experienced occupational and social impairment with reduced reliability and productivity, rather than occupational and social impairment with deficiencies in most areas. Because the evidence of record persuasively weighs against finding that the Veteran's PTSD caused more than occupational and social impairment with reduced reliability and productivity before May 2, 2017, or more than occupational and social impairment with deficiencies in most areas thereafter, the Veteran's claim for increased ratings for PTSD must be denied. 2. Increased Ratings for Lumbosacral Strain with Mild Degenerative Changes The Veteran contends that he is entitled to higher disability ratings for his lumbosacral strain with mild degenerative changes (back disability) because his current ratings of 0 percent before March 28, 2017, 10 percent before June 24, 2021, and 20 percent thereafter do not fully recognize or compensate for the severity of the Veteran's symptoms. The Veteran's back disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 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. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. 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. 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 also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background 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."). Under 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). Before March 28, 2017 The Board finds that the evidence of record persuasively weighs in favor of a 10 percent rating, but not higher, for the Veteran's back disability before March 28, 2017. In February 2016, a private examiner partially completed a standard VA disability benefit questionnaire for back conditions. They did not perform range of motion or muscle strength testing but did opine that the Veteran had mechanical back pain syndrome as well as intervertebral disc syndrome (IVDS) with fluctuating symptoms including intermittent locking of the back and bilateral lower extremity radicular pain. The private examiner identified factors contributing to the Veteran's disability including less movement than normal, weakened movement, pain with movement, instability of station, and interference with standing. Without specifics, the private examiner opined that the Veteran's back disability limited the weight he could pick up and limited his endurance at work. None of the Veteran's treatment records or VA examinations noted symptoms of, or gave diagnoses for, either radiculopathy or IVDS. The private examiner noted tenderness to palpation over the T12 L5 and paraspinous area. In August 2016, VA provided an examination to determine the cause and severity of the Veteran's back disability. Objective testing of the Veteran's range of motion by the August 2016 VA examiner showed more movement than normal, with forward flexion from 0 to 90 degrees and combined lumbar range of motion of 300 degrees. No objective signs of pain were observed and there was no evidence of pain with weight bearing. There was tenderness in the mid-thoracic area on both sides of the vertebral column which did not result in abnormal gait or abnormal spinal contour. The findings of both the private and VA examiner's identified localized tenderness not resulting in abnormal gait or abnormal spinal contour, consistent with the Veteran's lay statements and medical treatment records. A 10 percent rating is therefore warranted from April 4, 2014, to March 27, 2017. 38 C.F.R. § 4.71a, Diagnostic Code 5242. Regarding a rating greater than 10 percent, the Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain with prolonged standing, prolonged sitting, or body armor use, as well as the private examiner's report of less movement than normal, weakened movement, and instability of station. However, even considering these reports of symptoms and noted functional loss, the degree of additional limitation reflected by these statements would not result in limitation of motion more nearly approximating 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. Additionally, the Veteran did not have 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 rating greater than 10 percent for the Veteran's back disability, for the period before March 28, 2017, is not warranted. Consideration has also been given to assigning a rating under the Formula for IVDS Based on Incapacitating Episodes. However, even assuming arguendo that the private examiner was correct in diagnosing IVDS, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. The only indication that the Veteran has any associated neurological impairment is the private examiner's report of radicular pain in the bilateral legs and feet. The private examiner's report noted there were no objective findings to support the diagnosis of radiculopathy. The Veteran's medical records and the August 2016 VA examination performed approximately six months later contain no mention of lower extremity radiculopathy or related symptoms. The Board therefore finds that the evidence of record persuasively weighs against finding that the Veteran's back disability has caused or aggravated any neurological impairment. From March 28, 2017, to Before June 24, 2021 The Board finds that the evidence of record persuasively weighs against a rating in excess of 10 percent for the Veteran's back disability for the period from March 28, 2017, to before June 24, 2021. In March 2017, VA provided an examination to determine the severity of the Veteran's back disability. The Veteran reported daily pain with functional loss with bending over, sitting, and standing. He did not report any flare ups. Objective range of motion testing showed forward flexion from 0 to 70 degrees with combined range of motion of 210 degrees. Objective signs of pain were observed with motion. There was tenderness at the lower back to both sides of the spine, but this did not result in an abnormal gait or abnormal spinal contour. There was no change to the Veteran's range of motion after three repetitions and the examiner was unable to opine without resorting to speculation what the range of motion might have been after repeated use over time. The examiner did not diagnose IVDS or radiculopathy. In addition to the Veteran's previously diagnosed thoracic strain and mechanical back pain syndrome, x-rays taken with this examination showed mild lumbar degenerative disc disease (arthritis). The examiner opined that the Veteran's back disability would cause difficulty with sitting, standing, and lifting heavy items. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain which caused difficulty sitting, standing, and lifting. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he experienced pain when sitting for long periods, such as he often did for work, would not result in limitation of motion more nearly approximating 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. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Consideration has also been given to assigning a rating under the Formula for Rating IVDS Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Furthermore, effective February 7, 2021, Diagnostic Code 5243 was amended to read: "Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign diagnostic code 5242 for all other disc diagnoses." There is no evidence that the Veteran had disc herniation with compression and/or irritation of the adjacent nerve root. A rating for IVDS would therefore be unwarranted under both older and current versions of the rating criteria. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability during this period June 24, 2021, onward The Board finds that the evidence of record persuasively weighs against a rating in excess of 20 percent for the Veteran's back disability. In June 2021, VA provided an examination to determine the severity of the Veteran's back disability. The Veteran reported constant back pain which caused him difficulty doing dishes, bending over, carrying any type of weight, and getting to sleep. He complained that his back locked often but did not report flare ups. Objective range of motion testing showed forward flexion from 0 to 65 degrees with a combined range of motion of 175 degrees. There was pain with motion but no change in range of motion after three repetitions. However, the examiner opined that after repeated use over time the Veteran's forward flexion would be reduced to 45 degrees with a combined range of motion of 120 degrees. There was tenderness that did not result in abnormal gait or abnormal spinal contour. The examiner did not note ankylosis, IVDS, or radiculopathy. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain with prolonged standing, sitting, or any lifting. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he has increased pain with reduced limitation of motion, as well as locking, would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Effective February 7, 2021, Diagnostic Code 5243 was amended to read: "Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign diagnostic code 5242 for all other disc diagnoses." There is no evidence that the Veteran had disc herniation with compression and/or irritation of the adjacent nerve root. A rating for IVDS is therefore unwarranted. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability during this period. Conclusion An increased rating of 10 percent is warranted from April 4, 2014, for localized tenderness not resulting in abnormal gait or spinal contour. However, for the foregoing reasons, the evidence of record persuasively weighs against the Veteran's claim for a rating in excess of 10 percent for his back disability before June 24, 2021, and in excess of 20 percent thereafter. As the evidence of record persuasively weighs against these increased ratings, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir. Dec. 17, 2021) REASONS FOR REMANDS 1. Entitlement to service connection for a throat condition is remanded. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In June 2021, the Board remanded this issue and ordered the Agency of Original Jurisdiction (AOJ) to provide an examination to determine whether the Veteran's claimed throat condition was related to either his in-service pharymgitis or to exposure to burn pits. The order instructed, consistent with VA regulation, that the Veteran's deployment time and location alone were sufficient to concede exposure and further evidence of exposure was not required. Later in June 2021, a VA examiner provided an opinion on this issue. The examiner stated that the Veteran's documented chronicity of care for acute pharyngitis, which had occurred approximately every three years since service, could be related to burn pit exposure. However, the examiner stated, without further explanation, that only a treating medical provider could determine whether or not the condition was considered chronic. As no medical records reflected such a finding, the VA examiner opined there was no nexus established between the recurrent pharyngitis and the Veteran's service. This opinion is inaquate because it provided no explanation for why a review of the Veteran's record was inaquate for a reviewing examiner to determine whether a condition is considered chronic. Even assuming that this is true, a remand would be required to allow the Veteran an opportunity to ask his treatment provider to render such an opinion. Furthermore, the Veteran's primary claimed symptom of hyperactive gag reflex was noted by the examiner but not adequately addressed by their opinion. The Veteran's lay statement that this severe symptom began during service, confirmed by his spouse's lay observation of his daily gagging from attempting to brush his teeth, is sufficient to require an opinion as to the cause of this condition and whether it is at least as likely as not related to his service. A new opinionbased on full review of the record and supported by stated rationaleis needed to fairly resolve the appellant's claims. 2. Entitlement to service connection for a right elbow disability is remanded. In June 2021, the Board remanded this issue and ordered the AOJ to obtain National Guard/Reserve unit service and treatment records that might clarify whether the Veteran had any right elbow injury during active duty for training. These records have been obtained and show that the Veteran in August 2016 reported an injury to his right arm that occurred while lifting items into and out of a trailer. The Veteran was returned to duty with a restriction for lifting over 30 lobs with his right arm. The Board cannot make a fully-informed decision on the issue of service connection for a right elbow disability because no VA examiner has opined whether the Veteran has a current right elbow disability that is at least as likely as not related to his confirmed right arm injury noted in the August 2016 records. 3. Entitlement to service connection for a skin disability, to include a fungal infection and contact dermatitis, is remanded. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In June 2021, the Board remanded this issue and ordered the Agency of Original Jurisdiction (AOJ) to provide an examination to determine whether any of the Veteran's claimed skin conditions at least as likely as not began during service. Among other evidence, the Board ordered the examiner to consider the Veteran's competent lay statements. Later in June 2021, VA provided an examination to determine the nature and etiology of any skin condition. The examiner noted the Veteran's claim that he was prescribed ciclopirox olamine cream to be used on his feet and thighs, but that evidence of this was not found in the c-file. The examiner also noted the Veteran's claims of chronicity of symptoms since service but relied on the lack of continuous records of medical treatment to opine that there was no chronicity of care since service and the condition was less likely than not related to service. The Veteran's private dermatology records, dated May 2019 and received by VA in June 2021, show a prescription for ciclopirox cream to treat tinea pedis on both feet and to treat tinea cruris in the groin. This discrepancy indicates that the examiner did not review all of the relevant treatment records before forming their opinion. Furthermore, the examiner's belief that the Veteran's claims were not supported by the medical records may have caused them to discount his testimony regarding his chronicity of symptoms. For these reasons, the June 2021 VA examiner's opinions are inadequate to support a Board decision and a remand is required to obtain an adequate opinion on this issue. The matters are REMANDED for the following action: 1. Schedule a VA examination for the Veteran's claimed throat condition. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that the diagnosed chronic laryngitis (or any other diagnosed throat condition) is related to service either as a result of his in-service acute pharyngitis or through exposure to burn pits. In considering burn pit exposure, the Veteran's testimony that he was exposed to burn pits on deployment is considered sufficient in other words, it need not be documented in the service records. The examiner should specifically address the following: (a.) The etiology of the Veteran's hyperactive gag reflex, including whether it at least as likely as not had its onset during a period of active service; (b.) Whether the Veteran's recurrent pharyngitis, noted by the June 2021 VA examiner as possibly related to burn pit exposure, is at least as likely as not related to service, including conceded burn pit exposure. 2. Schedule the Veteran for a VA examination for his claimed right elbow disability. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion below. The examiner is asked to provide a response to the following: Does the Veteran have a right elbow disability that is at least as likely as not related to service, including right arm lifting injury noted in August 2016 service treatment records? Provide a rationale to support the opinion. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 3. Schedule a VA examination with an appropriately qualified examiner for the Veteran's claimed skin conditions. All diagnoses must be identified. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that the diagnosed skin conditions (specifically, but not limited to, dermatitis and trench foot) had their onset in service. In reaching this opinion, the examiner must consider all relevant evidence of record, to include the in-service records of dermatitis and 2019 record of a fungal rash due to wet weather, private dermatology records, and the Veteran's contentions regarding onset and current symptomatology. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If any benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zimmerman, Micah 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.