Citation Nr: 23019359 Decision Date: 03/29/23 Archive Date: 03/29/23 DOCKET NO. 18-22 933 DATE: March 29, 2023 ORDER Entitlement to an initial rating in excess of 20 percent for right lower extremity (RLE) radiculopathy, femoral nerve is denied. Entitlement to an initial rating in excess of 20 percent for RLE radiculopathy, sciatic nerve is denied. Entitlement to an initial rating in excess of 20 percent for left lower extremity (LLE) radiculopathy, femoral nerve is denied. Entitlement to an initial rating in excess of 20 percent for LLE radiculopathy, sciatic nerve is denied. REMANDED Entitlement to a rating in excess of 20 percent residuals, left ankle sprain (left ankle disability), beginning April 12, 2017 is remanded. Entitlement to service connection for loss of teeth, other than tooth number 7, for compensation purposes, to include as secondary to service-connected gastroesophageal reflux disease (GERD) and/or secondary to a respiratory disability and/or secondary to sleep apnea and/or secondary to a hiatal hernia is remanded. Entitlement to service connection for a left foot disability manifested in a skin condition is remanded. Entitlement to service connection for a vision/eye disability, to include as secondary to pain medication related to service-connected disabilities is remanded. Entitlement to service connection for a bladder disability, to include as secondary to service-connected back disability is remanded. Entitlement to service connection for a heart disability, to include as secondary to service-connected major depressive disorder (MDD) (including medications) and/or secondary to service-connected back condition (including medications) and/or secondary to service-connected left ankle condition (including medications) is remanded. Entitlement to an effective date prior to April 17, 2017 for the award of special monthly compensation (SMC) at the housebound rate, is remanded. Entitlement to an effective date prior to April 17, 2017 for the award of Dependents Educational Assistance (DEA) benefits under 38 U.S.C., Chapter 35 is remanded. FINDINGS OF FACT 1. Beginning April 17, 2017, the Veteran's bilateral lower extremity radiculopathy manifested in moderate incomplete paralysis of the left and right femoral nerves. 2. Beginning April 17, 2017, the Veteran's bilateral lower extremity radiculopathy manifested in moderate incomplete paralysis of the left and right sciatic nerves. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 20 percent for RLE radiculopathy, femoral nerve have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.124(a), Diagnostic Code 8526. 2. The criteria for entitlement to an initial rating in excess of 20 percent for RLE radiculopathy, sciatic nerve have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.124(a), Diagnostic Code 8520. 3. The criteria for entitlement to an initial rating in excess of 20 percent for LLE radiculopathy, femoral nerve have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.124(a), Diagnostic Code 8526 4. The criteria for Entitlement to an initial rating in excess of 20 percent for LLE radiculopathy, sciatic nerve have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.124(a), Diagnostic Code 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1970 to February 1973. He had additional Army National Guard service through December 1988. The appeal to the Board of Veterans' Appeals (Board) arose from May 2017 and November 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office. The Board remanded the matters for further development in February 2020. The Board notes that throughout the entirety of the appellate period, the Veteran has been in receipt of a 100 percent combined rating. Beginning April 17, 2017, the Veteran was in receipt of a 100 percent rating for major depressive disorder and had been assigned an SMC at the housebound rate. Prior to April 17, 2017, during the period on appeal, the Veteran was in receipt of a 100 percent combine rating, but was not in receipt of a 100 percent rating for any individual disability. Based upon foregoing reasons, the issue of a total disability rating based on individual unemployability in conjunction with the increased rating claims decided herein is found to be moot. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Buie v. Shinseki, 24 Vet. App. 242, 250 (2011). The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. 1. Entitlement to an initial rating in excess of 20 percent for right lower extremity (RLE) radiculopathy, femoral nerve is denied. 2. Entitlement to an initial rating in excess of 20 percent for RLE radiculopathy, sciatic nerve is denied. 3. Entitlement to an initial rating in excess of 20 percent for left lower extremity (LLE) radiculopathy, femoral nerve is denied. 4. Entitlement to an initial rating in excess of 20 percent for LLE radiculopathy, sciatic nerve is denied. Legal Criteria Diseases affecting the nerves are rated on the basis of degree of paralysis, neuritis, or neuralgia under 38 C.F.R. § 4.124a. Under Diagnostic Code 8520, a 10 percent rating is assigned for mild incomplete paralysis; a 20 percent rating is assigned for moderate incomplete paralysis; a 40 percent rating is assigned for moderately severe incomplete paralysis; and a 60 percent rating is assigned for severe incomplete paralysis with marked muscular atrophy. A maximum 80 percent evaluation is assigned for complete paralysis of the sciatic nerve where the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a. Under Diagnostic Code 8526, a 10 percent rating is assigned for mild incomplete paralysis; a 20 percent rating is assigned for moderate incomplete paralysis; and a 30 percent rating is assigned for severe incomplete paralysis. A maximum 40 percent evaluation is assigned for complete paralysis of the femoral nerve. Id. Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as "mild," "moderate," "moderately severe," and "severe." Spellers v. Wilkie, 30 Vet. App. 211, 219 (2018) ("DC 8520 does not define 'mild,' 'moderate,' 'moderately severe,' or 'severe,' or generally associate those terms with specific symptoms"). When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Although the Board has at times attempted to define these terms using dictionary definitions, those definitions are problematic because they "do little to explain the Board's understanding of these terms and do not 'disclos[e] that benchmark it employed to reach [its] conclusion.'" Casey v. McDonough, No. 21-7569, slip op. at 3 (Vet. App. Jan. 24, 2023) (mem dec) (Falvey, J.) (quoting Johnson v. Wilkie, 30 Vet. App. 245, 255 (2018) (discussing the Board's attempt to define the terms slight, mild, moderate, and severe in DC 8515). See also Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). With regard to Diagnostic Codes 8520 and 8526, although 38 C.F.R. § 4.120, 4.123, and 4.124 are "helpful in framing the analysis, [they] are not alone sufficient to explain the Board's decision absent an articulated connection to specific evidence." LeMon v. McDonough, No. 21-3949), 2022 U.S. App. Vet. Claims LEXIS 1998, *7 (Dec. 16, 2022) (mem dec) (Toth, J.). As explained in LeMon, these regulations leave gaps in defining the relevant terms that are filled by VA's Adjudication Manual, M21-1: The Board "is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons or bases." Overton v. Wilkie, 30 Vet. App. 257, 264 (2018). Clearly relevant to this case are M21-1 provisions regarding evaluations of paralysis of the sciatic and femoral nerves. The M21-1 describes mild incomplete paralysis as a disability "limited to sensory deficits that are lower graded, less persistent, or affecting a smaller area." Part V, sbpt. iii, ch. 12, sec. A.2.c. And moderate incomplete paralysis, per the M21-1, should be "reserved for the most significant cases of sensory-only impairment," where the sensory involvement covers "a larger area in the nerve distribution." Id. M21-1 examples of a moderate disability include "motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate." Id. And the M21-1 provides that a moderately severe evaluation (that is, a 40% rating) is available when there is "[m]otor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a higher level of limitation or disability." Id. Atrophy may, but need not, be present for a moderately severe rating. As concluded by the Court in LeMon, given the relevance of these provisions to rating disabilities of the peripheral nerves, "the Board's failure to mention the M21-1's relevant guidance in this area constitutes clear error." LeMon, at *7-*8. The Board will therefore mention, and apply, these definitions in the instant case. Factual Background The Veteran was provided a VA back examination in April 2017. The Veteran reported low back pain that radiated into his toes and numbness/tingling in his legs. There was no evidence of muscle atrophy, and the right knee was hypoactive during the reflex exam. The sensory exam showed decreased sensation throughout the RLE, but normal sensation throughout the LLE. The Veteran reported moderate constant pain, severe intermittent pain, moderate paresthesias, and moderate numbness in both the RLE and LLE. The examiner found the radiculopathy in the femoral and sciatic nerves to be of moderate severity in both lower extremities. The Veteran used a cane to maintain his balance due to weakness in his legs. The Veteran was provided a VA peripheral nerve examination in June 2021. The Veteran complained of numbness and tingling in his left leg. The Veteran reported mild intermittent pain, mild paresthesias, and mild numbness in his LLE; but no reported symptoms in the RLE. There was no evidence of muscle atrophy, an abnormal gait, or trophic changes. The reflex and sensory exams were normal. The examiner found the radiculopathy in the femoral and sciatic nerves showed incomplete paralysis of mild severity in both lower extremities. The Veteran reported no assistive devices for ambulation. Analysis Throughout the appellate period, the Veteran has been in receipt of 20 percent ratings for moderate incomplete paralysis of the sciatic and femoral nerves. In this case, the Board is satisfied that the Veteran's bilateral femoral and sciatic nerve impairments have manifested in moderate incomplete paralysis. There was no evidence of muscular atrophy or trophic changes in either extremity. The evidence of record shows the Veteran's symptoms were wholly sensory, and higher ratings are not warranted, as a "moderate" evaluation is the maximum that may be assigned for wholly sensory peripheral nerve symptoms. See 38 C.F.R. § 4.124a. The evidence is not in approximate balance and the evidence persuasively favors finding that the criteria for a rating in excess of 20 percent for RLE femoral radiculopathy, a rating in excess of 20 percent for LLE femoral radiculopathy, a rating in excess of 20 percent for RLE sciatic radiculopathy, and a rating in excess of 20 percent for LLE sciatic radiculopathy have not been met. Accordingly, the benefit-of-the-doubt doctrine does not apply, and the claims are denied. 38 U.S.C. § 5107(b). REASONS FOR REMAND 1. Entitlement to a rating in excess of 20 percent for a left ankle condition is remanded. In accordance with the February 2020 remand directives, the Veteran was afforded a new VA examination in June 2021 to determine the current severity of his service-connected left ankle disability. The Board notes that the VA examination did not comply with the requirements outlined in Sharp, and remand is necessary to provide a new examination that provides the range of motion estimates after repeated use over time. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). 2. Entitlement to service connection for loss of teeth, other than tooth number 7, for compensation purposes is remanded. In June 2021 the Veteran was provided with a VA examination and nexus opinion to determine the nature and etiology of any disability resulting in the loss of teeth, other than tooth #7. The February 2020 remand directives required the examiner to clearly identify and diagnos all dental disabilities, to include periodontal disease and loss of teeth. The examiner diagnosed the Veteran with "loss of tooth #24 due to trauma while on active duty." The examiner provided a negative nexus opinion for tooth #24. However, the Board finds the examination inadequate. Within the examination, the examiner noted that an old Panorex image from 2017 showed that all the teeth in his mouth, besides #22 and #27 had been extracted. Accordingly, the examiner should have provided an opinion and rationale which addressed all the "lost teeth," not just #24. Stegall v. West, 11 Vet. App. at 270-71 (1998). Additionally, the Veteran has asserted that his tooth loss was related to his use of an albuterol inhaler, sleep apnea, a hiatal hernia and GERD. See November 2010 Congressional; May 2012 Hearing Testimony; January 2016 Correspondence; June 2020 Correspondence. The Board notes that the Veteran is service connected for GERD, and therefore an addendum opinion is necessary to determine whether the GERD caused or aggravated the Veteran's loss of teeth. 3. Entitlement to service connection for a left foot disability manifested in a skin condition is remanded. In February 2020, the remand directives required the Veteran be provided a VA examination or examinations to clearly identify and diagnose his left foot disabilities to include blisters and dyshidrotic eczema. The Veteran was provided a VA foot condition examination in June 2021; however, the Veteran was not provided a VA skin examination which was also necessary to address the Veteran's claims of manifestations of skin disorders on his left foot. Id. Additionally, the June 2021 VA foot examination noted that the Veteran had left foot tinea pedis. The Veteran's service treatment records (STRs) show evidence of tinea pedis in November 1970 and August 1972; yet, within the opinion, the examiner did not provide an opinion as to whether the Veteran's current tinea pedis incurred during or was caused by active-duty service. Id. For the foregoing reasons, the Veteran should be provided a VA skin examination, followed by an addendum opinion to determine the nature and etiology of the Veteran's left foot condition. The Board notes that this left foot disability claim is separate from pes planus, for which the Veteran is already in receipt of service-connection. 4. Entitlement to service connection for a vision/eye disability, to include as secondary to pain medication related to service-connected disabilities is remanded. The Veteran was provided with a VA eye condition examination in January 2021. The examiner diagnosed the Veteran with bilateral complexion associated conjunctival melanosis/racial melanosis, bilateral cataracts, and bilateral dry eye syndrome. The examiner provided negative nexus opinions, in part, noting that there was no evidence of eye ailments in service. The Board notes that this is inaccurate because the Veteran's was diagnosed with anisometropia, an eye disorder in January 1971 STRs. The Board finds the opinions inadequate, as the rationale for the opinion was based on an inaccurate factual basis. Reonal v. Brown, 5 Vet. App. 458 (1993). Additionally, the Veteran asserted that gabapentin, pain medication related to his service-connected disabilities, caused his vision problems. See January 2016 Correspondence. The Veteran's VA treatment records show prescriptions for gabapentin, and to date, no opinion has been provided to determine whether the vision disabilities are secondary to the Veteran's prescribed gabapentin. Accordingly, remand is necessary in order to obtain addendum opinions to determine the nature and etiology of the Veteran's vision disabilities. 5. Entitlement to service connection for a bladder disability, to include as secondary to service-connected back disability is remanded. The Veteran was afforded a VA urinary tract examination in June 2021. During the examination, he reported having increased urinary frequency, including a daytime voiding interval between two to three hours and nighttime awakening to void three to four times. The examiner noted voiding dysfunction. Despite the foregoing, the VA examiner did not render a relevant diagnosis, instead finding there were no findings, signs, or symptoms to support a diagnosis. The examiner provided a negative nexus opinion, in part, because the Veteran's complaints were subjective and there were no verified bladder diagnoses. The June 2021 VA examination and opinion are inadequate because the examiner did not adequately address whether the Veteran's various bladder complaints result in functional impairment in earning capacity such to be considered a disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Due to the fact the Veteran is service connected for a lumbar spine disability, an adequate opinion is necessary to determine if his voiding dysfunction is a neurological abnormality related to the lumbar spine disability. 6. Entitlement to service connection for a heart disability is remanded. The Veteran has asserted that his heart disability was caused by his MDD and/or pain medications prescribed for his back and ankle disabilities. See October 2010 Correspondence; December 2010 Correspondence; February 2011 Congressional. In February 2020, the remand directives required the Veteran be provided a VA examination and nexus opinion, in part, to determine whether his heart disability was caused or aggravated by medications taken to treat his service-connected MDD and back conditions. The Veteran was provided a VA heart condition examination in June 2021. The examiner provided a negative nexus opinion, but the examiner did not address aggravation or the impact of prescribed medications on the heart condition as directed by the previous remand. Accordingly, the Veteran should be provided an addendum opinion to ensure substantial compliance with the prior remand directives. Stegall, 11 Vet. App. at 271. 7. Entitlement to effective dates prior to April 17, 2017 for the award of SMC at the housebound rate and for the award of DEA benefits under 38 U.S.C., Chapter 35 are remanded. Readjudication of the service connection claims remanded herein may impact the Veteran's SMC and DEA claims; and therefore these claims are inextricably intertwined. Accordingly, all of these claims must be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following actions: 1. The AOJ should schedule the Veteran for a VA examination for his service-connected left ankle disability with a qualified clinician who has reviewed the claims file in conjunction with the examination. The most current Disability Benefits Questionnaire must be employed, and all relevant findings indicated in that questionnaire must be addressed. In so doing, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups and repeated use over time based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 2. The AOJ should schedule the Veteran for a VA addendum opinion with a qualified clinician who has reviewed the claims file in order to determine the nature and etiology of the Veteran's loss of teeth. The contents of the entire electronic claims file, to include a complete copy of this REMAND, must be made available to the designated examiner, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. The examiner is asked to address the following: Identify and diagnose all dental disabilities (to include periodontal disease and loss of teeth) currently present or present at any point pertinent to the current claim (even if now asymptomatic or resolved); To the extent that the Veteran has contended that he has suffered loss of teeth as a result of trauma during service, the examiner should specifically determine whether the Veteran has suffered loss of teeth (other than tooth #7) due to the loss of substance of the body of the maxilla or mandible; For each current dental disability involving loss of teeth (other than tooth #7), due to loss of substance of the body of the maxilla or mandible, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it is approximately at least as likely as not (at least an approximate balance of positive and negative evidence), that the disability had its onset during, or is otherwise medically related to, the Veteran's active service, to specifically include as a result the noted trauma that the Veteran suffered in August 1971, apparently resulting in teeth numbers 23 and 24 becoming luxated; For each current dental disability involving loss of teeth (other than tooth #7), due to loss of substance of the body of the maxilla or mandible, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it approximately at least as likely as not was caused by GERD; and For each current dental disability involving loss of teeth (other than tooth #7), due to loss of substance of the body of the maxilla or mandible, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it approximately at least as likely as not was aggravated by GERD. In addressing the above, the examiner must consider and discuss all relevant medical evidence, and the Veteran's competent assertions as to the nature, onset, and continuity of symptoms. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. 3. The AOJ should schedule the Veteran for a VA skin examination with a qualified clinician who has reviewed the claims file in order to determine the nature and etiology of the Veteran's left foot disability. The contents of the entire electronic claims file, to include a complete copy of this REMAND, must be made available to the designated examiner, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. The examiner is asked to address the following: Identify and diagnose all left foot skin disabilities currently present or present at any point pertinent to the current claim (even if now asymptomatic or resolved); and For each current disability, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it is approximately at least as likely as not (at least an approximate balance of positive and negative evidence), that the disability had its onset during, or is otherwise medically related to, the Veteran's active service. In addressing the above, the examiner must consider and discuss all relevant medical evidence, and the Veteran's competent assertions as to the nature, onset, and continuity of symptoms. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. 4. The AOJ should schedule the Veteran for an addendum opinion with a qualified clinician who has reviewed the claims file in order to determine the nature and etiology of the Veteran's vision/eye disability. The contents of the entire electronic claims file, to include a complete copy of this REMAND, must be made available to the designated examiner, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. The examiner is asked to address the following: Identify and diagnose all vision and/or eye disabilities currently present or present at any point pertinent to the current claim (even if now asymptomatic or resolved); For each current disability, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it is approximately at least as likely as not (at least an approximate balance of positive and negative evidence), that the disability had its onset during, or is otherwise medically related to, the Veteran's active service; For each current disability, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it approximately at least as likely as not was caused by gabapentin; and For each current disability, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it approximately at least as likely as not was aggravated by gabapentin. In addressing the above, the examiner must consider and discuss all relevant medical evidence, and the Veteran's competent assertions as to the nature, onset, and continuity of symptoms. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. 5. The AOJ should schedule the Veteran for an addendum opinion with a qualified clinician who has reviewed the claims file in order to determine the nature and etiology of the Veteran's bladder disability. The contents of the entire electronic claims file, to include a complete copy of this REMAND, must be made available to the designated examiner, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. The examiner is asked to address the following: Consistent with sound medical principles, whether it is approximately at least as likely as not (at least an approximate balance of positive and negative evidence), that the Veteran's voiding dysfunction had its onset during, or is otherwise medically related to the Veteran's active service; and The examiner should provide a medical opinion, consistent with sound medical principles, as to whether the voiding dysfunction approximately at least as likely as not was caused by the service-connected back condition; and The examiner should provide a medical opinion, consistent with sound medical principles, as to whether the voiding dysfunction approximately at least as likely as not was aggravated by the service-connected back condition. In addressing the above, the examiner must consider and discuss all relevant medical evidence, and the Veteran's competent assertions as to the nature, onset, and continuity of symptoms. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. 6. The AOJ should schedule the Veteran for an addendum opinion with a qualified clinician who has reviewed the claims file in order to determine the nature and etiology of the Veteran's heart disability. The contents of the entire electronic claims file, to include a complete copy of this REMAND, must be made available to the designated examiner, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. The examiner is asked to address the following: Identify and diagnose all heart disabilities currently present or present at any point pertinent to the current claim (even if now asymptomatic or resolved); For each current disability, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it is approximately at least as likely as not (at least an approximate balance of positive and negative evidence), that the disability had its onset during, or is otherwise medically related to, the Veteran's active service; For each current disability, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it approximately at least as likely as not was caused by MDD (to include stress and medication related to MDD); For each current disability, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it approximately at least as likely as not was aggravated by MDD (to include stress and medication related to MDD); For each current disability, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it approximately at least as likely as not was caused by service-connected back or left ankle conditions (to include medications such as propoxyphene); and For each current disability, the examiner should provide a medical opinion, consistent with sound medical principles, as to whether it approximately at least as likely as not was aggravated by service-connected back or left ankle conditions (to include medications such as propoxyphene). (Continued on next page) ? In addressing the above, the examiner must consider and discuss all relevant medical evidence, and the Veteran's competent assertions as to the nature, onset, and continuity of symptoms. Consideration of articles and treatise evidence submitted by the Veteran must be considered. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. J. Abrams Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. N. Quarles, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.