Citation Nr: 23020331 Decision Date: 04/03/23 Archive Date: 04/03/23 DOCKET NO. 17-26 019 DATE: April 3, 2023 ORDER 1. Entitlement to service connection for an acquired psychiatric disability is granted. 2. A 10 percent, but no higher, rating from January 11, 2022 for the right little finger disability is granted. 3. Entitlement to a compensable rating for atopic dermatitis of the chest and neck is denied. REMANDED 4. Entitlement to service connection for a hernia disability is remanded. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Competent (medical) evidence reasonably establishes that that Veteran's acquired psychiatric disability is related to traumatic events in service. 2. From January 11, 2022, the Veteran's right little finger disability is reasonably shown to have been manifested by pain, limited range of motion, and reduced grip strength resulting in overall functional impairment of the hand. 3. The Veteran's atopic dermatitis does not affect at least five percent of the entire body or of exposed areas and did not require intermittent systematic therapy or other immunosuppressive drugs for a total duration of less than six weeks during a 12-month period. CONCLUSIONS OF LAW 1. Service connection for an acquired psychiatric disability is warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. A 10 percent rating for the Veteran's right little finger disability is warranted from January 11, 2022; prior to that date, a compensable rating for the right little finger disability is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.14, 4.55, 4.56, 4.71a, 4.73, Diagnostic Codes (Codes) 5227, 5230, 5309. 3. A compensable rating for the Veteran's atopic dermatitis of the chest and neck is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Code 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1987 to June 1995. These matters are before the Board of Veterans' Appeals (Board) on appeal of a May 2013 Department of Veterans Affairs (VA) rating decision. In July 2022, the Board remanded these matters and the matters of service connection for bilateral eye and bilateral ankle disabilities. A February 2023 rating decision awarded service connection for bilateral eye and bilateral ankle disabilities, fully resolving those matters. The Veteran initially requested a Board hearing. On a statement from the representative dated in May 2022, it was requested that a Board hearing be cancelled. Therefore, the Board considers the hearing request withdrawn. At the outset, the Board finds there has been substantial compliance with its July 2022 remand directives pertaining to the matters of service connection for an acquired psychiatric disability and increases in the ratings for atopic dermatitis and right little finger. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Service Connection 1. Service connection for an acquired psychiatric disability is granted. Service connection may be established for disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To establish service connection for a claimed disability, there must be evidence of: (i) a present claimed disability; (ii) incurrence or aggravation of a disease or injury in service; (iii) and a causal relationship ("nexus") between the present disability and the disease or injury in service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Secondary service connection is warranted for a disability which is caused or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. To substantiate a claim of secondary service connection there must be evidence of: (1) a disability for which service connection is sought; (2) a disability that is already service connected; and (3) the already service-connected disability caused or aggravated the disability for which service connection is sought. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). Competent medical evidence is necessary where the determinative question requires medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). VA is responsible for determining whether the evidence persuasively favors one side or another. 38 C.F.R. § 4.3. When there is an approximate or nearly equal balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the Veteran and the claim will be granted on the merits. 38 U.S.C. § 5107(b). When the evidence persuasively favors against the claims of the Veteran, the benefit of the doubt doctrine is inapplicable and the claim will be denied on its merits. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) (en banc). The Veteran contends that his psychiatric disability is related to service and, in part, to the injuries he sustained in service. In the May 2017 substantive appeal, the Veteran reported that he hit his head many times while running through passages on the ship and hurt his ankles falling down ladders or stairways, which was "mentally stressful and has caused an affect on [him] to this day." In a May 2022 statement by a private psychologist (Dr. J.G.), major depressive disorder with anxious distress was diagnosed in accordance with the DSM-5 criteria. The provider opined the Veteran's major depression with anxious distress is at least as likely as not due to, the result of, or was incurred during military service, based on a review of the record, general clinical literature in the area, and a clinical interview of the Veteran. The provider noted the Veteran did not have any mental health psychopathology prior to service, and, during service, reported several injuries and stressful circumstances which occurred in service. The provider noted these events included being present when a shipmate fell overboard and could not be rescued, injuries to his ankles, injuries to his eyes, and other incidents involving his head and fingers. Citing to the DSM-5 criteria, the provider noted "stressful events are well recognized as precipitants of major depressive episodes." The provider stated since the events in service, the Veteran struggles with depression. The provider opined there is a clear nexus between the Veteran's major depressive disorder and his service, noting there is no equally compelling etiology for this condition and his symptoms are chronologically, functionally, and thematically consistent with the Veteran's military service. In an October 2022 VA examination, unspecified depressive disorder in accordance to the DSM-5 criteria was diagnosed. The examiner noted medical diagnoses related to the understanding or management of the mental health disorder include hernia, back pain, and atrial fibrillation. The examiner opined that it is less likely than not that the Veteran's current mental health symptoms are related to or caused by his military service, noting that he first sought mental health treatment in the last year and the first documentation of mental health treatment contained in VA records was over 25 years after service. The examiner noted the Veteran reported that he continued to be upset about things he experienced in the military and also noted that "it appeared that most of the Veteran's reported symptoms were in response to the loss of his sister and mother, rather than his experiences in the military" when discussing his current symptoms. The examiner opined that the Veteran appeared to be "functioning fairly well" following his discharge, citing to him remaining married for nine additional years and holding two stable jobs for about six years each. In February 2023, Dr. J.G. provided an addendum opinion to his prior report from May 2022 and addressed the October 2022 VA opinion. The provider continued to opine that the Veteran's major depressive disorder was at least as likely as not related to service. The provider again noted that the Veteran reported several injuries and stressful circumstances in service, including being present when a shipmate fell overboard, injuries to his ankles, injuries to his eyes, and other incidents including his head and finger. The provider addressed the VA examiner's three main contentions against the claim: (1) his current symptoms appeared to be in response to the deaths of his mother and sister, (2) he appeared to be functioning well after service with maintaining his marriage for nine more years and holding down two stable jobs for six years each, and (3) he was first treated for a mental health condition 25 years after service. In response to the VA examiner's first contention, the provider noted there is no diagnostic criteria or differential diagnostic consideration listed in the DSM-5 that states that a person with depressive disorder must only struggle with or talk about the events which occurred at the time of the diagnosis originally manifested. The provider stated major depressive disorder is diagnosed upon evidence of the first major depressive episode and, following this, a patient may have some baseline symptoms and eventually are likely to have additional major depressive episodes, often in response to emergent life stressors. The provider noted depressive disorders make coping with stress and circumstances more difficult. The provider acknowledged the Veteran's reports of struggling with post-military deaths in his immediate family, but opined those reports in no way negate the etiology of the major depressive disorder with military service. In response to the VA examiner's second contention, the provider reasoned the idea that being able to be married or hold a stable job weighs against the presence of a mental illness is inconsistent with the DSM-5 and is "indicative of mental health stigma." The provider noted people with PTSD put on a "social mask" and may appear to be doing well or successful when in reality they struggle everyday with their mental illness. In response to the VA examiner's third contention, the provider noted the absence of mental health care is not synonymous with the absence of a mental health condition. Citing to medical literature, the provider reported that more than half of all people with a mental illness were not receiving treatment and approximately 35% of adults with major depressive episode will never receive treatment. It is not in dispute that the Veteran has an acquired psychiatric condition. It is also not in dispute that he injured his ankles, eyes, and finger in service. He has been awarded service connection for left ankle, right ankle, right little finger, and bilateral nuclear sclerosis with dry eye syndrome due to injuries in service. There are conflicting medical opinions regarding the etiology of the Veteran's current acquired psychiatric disability. The Board finds the May 2022/February 2023 opinions by the private psychologist place the evidence regarding whether the Veteran has a psychiatric diagnosis due to/caused by his service at least in equal balance with the evidence weighing against him having such diagnosis. In the May 2022 and updated February 2023 opinions in support of the claim, the private psychologist expressed familiarity with the Veteran's record/medical history, and included rationale that cited to accurate factual data. The provider considered, and ruled out, the contrary contentions made by the VA examiner, to reach the conclusion in support of the claim. The provider has subject matter expertise and is competent to offer the opinion. Accordingly, the Board finds the May 2022/February 2023 medical opinions persuasive. The October 2022 VA examiner's opinion against the claim is largely based on the absence of contemporaneous medical treatment. Moreover, the VA examiner did not address the May 2022 opinion in the opinion to the contrary. Therefore, the Board finds it has lesser probative value. Considering the foregoing, the Board finds the finds the probative value of the evidence supporting the Veteran's claim is, at least, in approximate or nearly equal balance with the evidence against the claim. In such circumstances governing law (38 U.S.C. § 5107; 38 C.F.R. § 3.102) requires that reasonable doubt must be resolved in the Veteran's favor. Accordingly, the Board finds that the criteria for establishing service connection are met; service connection for an acquired psychiatric disability is warranted. [Due process requires that the AOJ be afforded initial opportunity to implement the awards of service connection, assigning a disability rating and an effective date.] Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Separate ratings for distinct periods when varying degrees of disability were shown can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA regulations allow for the assignment of an increased rating up to one year prior to receipt of a formal claim for increase, when it is factually ascertainable that an increase in disability had occurred. 38 C.F.R. §§ 3.157, 3.400(o)(2). Where there is a question as to which of two ratings shall be assigned, the higher criteria will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. VA is responsible for determining whether the evidence persuasively favors one side or another. 38 C.F.R. § 4.3. When there is an approximate or nearly equal balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant and the claim will be granted on the merits. 38 U.S.C. § 5107(b). When the evidence persuasively favors against the claims of the Veteran, the benefit of the doubt doctrine is inapplicable and the claim will be denied on its merits. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) (en banc). 2. A 10 percent rating from January 11, 2022 for a right little finger disability is granted. A finger disability is rated under Codes 5216 through 5230 for evaluation of ankylosis or limitation of motion of single or multiple digits of the hand. 38 C.F.R. § 4.71a. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, these diagnostic codes were not changed. A little finger disability is specifically rated under Codes 5227 or 5230. Under Code 5230, any ring or little finger limitation of motion is rated 0 percent. Under Code 5227 ankylosis of a ring or little finger, favorable or unfavorable, is rated 0 percent. A Note following Code 5227 requires consideration of whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. See 38 C.F.R. § 4.71a, Code 5227, Note (1). Code 5309 (for injury to Muscle Group IX, which includes the intrinsic muscles of the hand, to include 4 dorsal and 3 palmar interossei) explains that forearm muscles act in strong grasping movements and are supplemented by the intrinsic muscles in delicate manipulative movements. A Note following Code 5309 provides that because the hand is so compact, isolated muscle injuries are rare and muscle injuries instead are nearly always complicated with injuries of bones, joints, tendons, ect. The disability is to be rated based on limitation of motion, with the minimum rating being 10 percent. See 38 C.F.R. § 4.73. The Veteran's claim for an increased rating for his right little finger was received on August 18, 2010. The relevant period for consideration therefore begins one year earlier, in August 2009. An August 2010 VA treatment record notes the Veteran's muscle strength was 5/5 in all four extremities. An August 2020 VA treatment records notes the Veteran went to the emergency room due to chest pain and was admitted into critical care. His right grip strength was found normal on repetitive testing during his hospitalization. At the January 11, 2022 VA examination, the Veteran reported his finger was more swollen and the pain has increased. He reported he had difficulty gripping objects with his right hand. On examination, there was limitation motion with this right little finger. There was evidence of pain with active and passive motion and the examiner opined it caused functional loss, described as difficulty gripping objects with the right hand. Additional factors that contributed to the disability included swelling. Muscle strength testing of the right-hand grip was reduced to 4/5 due to the right little finger disability. There was no ankylosis. The examiner opined that right hand function was not so diminished that amputation with prosthesis would equally serve the Veteran and that the right-hand disability would have some functional impact such as difficulty gripping objects with his right hand. The Veteran's right little finger disability is currently rated 0 percent under Code 5229-5227. The hyphenated code indicates that the right little finger fracture disability is rated, by analogy, to the criteria for rating limitation of motion of the index or long finger (Code 5229) and ankylosis of the ring or little finger (Code 5227). Notably, limitation of motion of the little finger is most appropriately characterized under Code 5230, for ring or little finger, limitation of motion. However, 0 percent is the maximum rating afforded for ankylosis or limitation of motion for the little finger under Codes 5227 and 5230. The Board has considered whether a rating as amputation is warranted under the Note following Code 5227. As the January 2022 examiner specifically found that remaining hand function exceeded what would be equally well-served by amputation and a prosthesis, a rating as amputation is not warranted. Remaining for consideration is whether a rating is warranted for interference with overall function of the hand. See Code 5227, Note (1). For guidance in rating the resulting interference with the overall function of the hand, the Board looks to the note following Code 5309 (for intrinsic muscles of the hand which control grasping), which provides for rating based on limitation of motion, with the minimum rating being 10 percent. The Board finds that a 10 percent rating for interference with overall function of the hand is warranted from January 11, 2022. See Note following Code 5227. From January 11, 2022, the Veteran has demonstrated limitation of hand grip with 4/5 (reduced) strength. The January 2022 VA examiner found the disability causes difficulty gripping objects with his right hand. Prior to that date, the neither the VA treatment records nor the Veteran's statements indicate he experienced limited grip strength due to his right little finger disability. Accordingly, a 10 percent rating from January 11, 2022, but no earlier, is warranted for the Veteran's right little finger disability. 3. Entitlement to a compensable rating for his atopic dermatitis is denied. Skin disabilities are rated under 38 C.F.R. § 4.118. The Veteran's atopic dermatitis of the neck has been rated under Code 7806. During the pendency of the appeal, the rating criteria for evaluating skin disabilities under 38 C.F.R. § 4.118 were amended effective August 13, 2018. As the period under consideration here is from August 18, 2009 (the year prior to the receipt of his claim for an increased rating for his skin disability) to the present, the Veteran is entitled to a rating under either the prior or the revised (from their effective dates, if more favorable) criteria. See VAGCPREC 3-2000. Under the pre-amendment Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. The rule also provides the rating may be made as disfigurement of the head, face, or neck (Code 7800) or scars (Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 31, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Under the amended rating criteria for skin disabilities, a new General Rating Formula for the Skin applies to Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. The General Rating Formula for the Skin provides that a noncompensable (0 percent) rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. The rule also provides the rating may be made as disfigurement of the head, face, or neck (Code 7800) or scars (Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for Codes 7806, 7809, 7813-7816, 7820-7822, and 7824. In his August 18, 2010 formal claim, the Veteran reported he had dry skin / dermatitis on his neck, chest, nape, and arms. An August 2010 VA treatment record notes his skin color and texture were found normal on examination. In his January 2014 notice of disagreement, the Veteran reported he had dry skin / dermatitis on his chest, neck, arms, and legs. In the January 2022 VA examination, atopic dermatitis of the neck and chest was diagnosed. The examiner noted that the Veteran's skin condition did not cause scarring of the head, face or neck. The condition did not require treatment with medication in the past 12 months and had not had any treatments or procedures other than systemic or topical medications in the past 12 months for the condition. The condition affected less than 5 percent of total body area and exposed body area. The condition caused scaly raised areas of dry skin on his neck and chest. It had no impact on his ability to work. In a February 2022 statement, the Veteran reported he had dry skin with lingering symptoms. He reported he has to use lotion or Vaseline on a regular basis for his dermatitis. The Board finds that a compensable rating for atopic dermatitis is not warranted. The Veteran's treatment records, VA examination, or own statements do not show his skin disability covered at least 5 percent, but less than 20 percent, of his entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. At most, the condition affected less than 5 percent of his total and/or exposed body areas. There is no indication that his reported use of lotion/Vaseline affected the body as a whole in treating the Veteran's skin condition; thus, it is not considered systematic therapy. The Board has considered whether a compensable rating is warranted under the amended criteria and finds it is not. The Veteran's atopic dermatitis of the neck and chest does not more nearly approximate characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. The Board acknowledges that the Veteran believes that his skin disability on appeal has been more severe than the assigned disability rating reflects. The Veteran is competent to report observable symptoms, to include that the skin condition, and his reports are credible. Jandreau, 492 F.3d at 1376-77. However, the medical evidence does not show that the Veteran's disability more nearly approximates the criteria in the next higher rating. Notably, while the Veteran reported some locations of his dermatitis, the evidence does not persuasively show that the skin condition effect more than 5 percent of his total and/or exposed body areas. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. Here, the evidence shows that the predominate disability at issue is atopic dermatitis. Specifically, service connection has been awarded for atopic dermatitis of the neck and chest. Accordingly, the Board finds that the evidence weighs persuasively against this claim. The benefit of the doubt doctrine, see 38?U.S.C. §?5107(b), is therefore not for application as to this claim. Lynch, 21 F.4th at 781. The claim must be denied. REASONS FOR REMAND 4. Entitlement to service connection for a hernia disability. The Veteran alleges that his hernias were due to heavy lifting in service and that he felt intense strain below his stomach while passing heavy boxes in service. See February 2022 statement. His service treatment records (STRs) note complaints of abdomen pain and abdomen cramps. VA treatment records reflect he has undergone three surgeries to repair hernias. The Veteran has not been afforded a VA examination to determine the nature and etiology of his claimed hernia disability. Considering his contentions and the state of the medical evidence of record, an examination to secure a medical opinion regarding the nature and likely etiology of his pulmonary disability is needed. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Entitlement to a TDIU rating. In a December 2021 VA Form 21-8940, the Veteran asserted he is unable to maintain substantially gainful employment due to all his service-connected disabilities. An April 2022 rating decision denied entitlement to a TDIU rating. While he did not submit a notice of disagreement following the April 2022 rating decision, he had timely perfected an appeal in the matters of increased ratings for his right little finger and skin disabilities. A claim for entitlement to a TDIU rating is considered part and parcel of the increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Additionally, once entitlement to a TDIU rating is at issue as part of a claim for an increased rating (here, increased ratings for his right little finger and skin disabilities), a claimant does not need to appeal a denial by the Agency of Original Jurisdiction (AOJ) for the issue to remain in appellate status. Payne v. Wilkie, 31 Vet. App. 373 (2019). Accordingly, the Board has jurisdiction to address the issue of entitlement to a TDIU rating. Entitlement to a TDIU rating is inextricably intertwined with the rating and effective date assigned for service connection for an acquired psychiatric disability, granted herein. Therefore, consideration of the matter is deferred pending promulgation of the Board's grant of service connection for a psychiatric disability and staged rating for his right little finger disability. The matters are REMANDED for the following: 1. Arrange for the Veteran to be examined by an appropriate clinician to determine the nature and likely etiology of his claimed hernia disability. The examiner must review the Veteran's record and this remand. On examination of the Veteran and review of his record, the consulting provider should: (a.) Identify (by diagnosis) any hernia disability entity found/or shown by the record. (b.) Identify the likely etiology for each hernia disability entity diagnosed. Specifically, is it at least as likely as not (the likelihood is at least approximately balanced or nearly equal, if not higher) that it is etiologically related to the Veteran's active service, to include abdomen complaints, therein, and/or reports of heavy lifting. (c.) If a diagnosed hernia disability is found to be unrelated to service, identify the etiology that is considered to be more likely (and explain why that is so). A complete rationale should be provided for any opinion expressed. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). 2. Upon readjudication of the other claim remanded and promulgation of the grants herein, readjudicate the claim for a TDIU rating considering that determination as well as the Board's grant of service connection for an acquired psychiatric disability and staged increased rating for a right little finger disability. S. CHARLES NEILL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Naumovich, Alexa 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.