Citation Nr: 24005652 Decision Date: 02/02/24 Archive Date: 02/02/24 DOCKET NO. 20-19 110 DATE: February 2, 2024 ORDER As new and material evidence has been received, the application to reopen the previously denied claim for service connection for a low back disability is granted, to this extent only. Service connection for pseudofolliculitis barbae is granted. Service connection for adjustment disorder with depressed mood (claimed as insomnia), for the period on appeal prior to July 20, 2020 is granted. Service connection for a separate sleep disorder is denied. REMANDED Entitlement to service connection for a low back disability, to include degenerative joint disease of the lumbar spine, is remanded. Entitlement to service connection for a neurological disability associated with the sciatic nerve is remanded. Entitlement to service connection for a cervical spine disability, including degenerative joint disease of the cervical spine, is remanded. Entitlement to service connection for a bilateral foot/ankle disability is remanded. Entitlement to an initial compensable disability rating for the service-connected bilateral hearing loss disability is remanded. FINDINGS OF FACT 1. In an October 2004 rating decision, the RO denied service connection for a low back disability; no Notice of Disagreement or new and material evidence was received within one year of notification of the decision. 2. Evidence received since the October 2004 rating decision was not previously of record and relates to unestablished facts necessary to substantiate the claim of service connection for a low back disability, and raises a reasonable possibility of substantiating the claim. 3. The Veteran's pseudofolliculitis barbae was incurred during service. 4. For the entire period on appeal prior to July 20, 2020, the Veteran has a diagnosis of adjustment disorder with depressed mood which includes the symptom of insomnia, and which is proximately due to the service-connected sinusitis with sinus headaches. 5. The Veteran does not have a sleep disorder diagnosis separate from his insomnia symptoms that are already attributed to his service-connected adjustment disorder with depressed mood. CONCLUSIONS OF LAW 1. The October 2004 rating decision that denied service connection for a low back disability is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. Evidence received since the October 2004 rating decision is new and material and sufficient to reopen the previously denied claim for service connection for a low back disability. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for service connection for pseudofolliculitis barbae have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. For the entire period on appeal prior to July 20, 2020, the criteria for service connection for adjustment disorder with depressed mood, which includes the symptom of insomnia, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a separate sleep disorder (claimed as insomnia) have not been met. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1982 to July 1985 and from December 1985 to August 1990. This case is before the Board of Veterans' Appeals (Board) on appeal from a March 2018 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that decision, the RO granted service connection for a bilateral hearing loss disability and assigned an initial noncompensable disability rating, effective from February 5, 2018; denied service connection for a cervical spine disability, insomnia, plantar fasciitis, and pseudofolliculitis barbae; and denied reopening of the previously denied claim for service connection for a low back disability because new and material evidence had not been received. In July 2018, VA received the Veteran's NOD. In April 2020, the RO issued a Statement of the Case (SOC). In April 2020, VA received the Veteran's VA Form 9, substantive appeal to the Board. In January 2023, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that testimony is of record. At the outset, in a September 2020 rating decision issued during the pendency of the appeal, the RO granted service connection for adjustment disorder with depressed mood and assigned an initial disability rating of 50 percent, effective from July 20, 2020. However, in the present case, the insomnia issue dates back to a February 5, 2018 claim. Importantly, a claim for service connection for a psychiatric disorder includes all reasonably encompassed psychiatric diagnoses. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Here, the Veteran's diagnosis of adjustment disorder with depressed mood is reasonably encompassed by his earlier claim for service connection for insomnia with regard to the appeal period prior to the current July 20, 2020 effective date for service connection for adjustment disorder with depressed mood. Accordingly, the issue of service connection for insomnia is expanded to include as part and parcel of the service-connected adjustment disorder with depressed mood for the period on appeal prior to July 20, 2020. Finally, following the April 2020 SOC, the RO obtained the following VA examinations: a July 2020 VA audiological examination; a September 2020 VA psychiatric examination; and a March 2021 VA skin examination. While the above evidence was received after certification of the case to the Board, the grants of service connection for pseudofolliculitis barbae and adjustment disorder with depressed mood (prior to July 20, 2020) constitute full grants of benefits sought on appeal, and therefore, there is no prejudice to the Veteran in this regard. Moreover, as discussed below, service connection for a separate sleep disorder must be denied as a matter of course because the Veteran's claimed insomnia symptoms have been associated with a service-connected mental health disorder and the Veteran has not asserted that he has a separate sleep disorder. In any case, the evidence noted above was addressed in September 2020 (psychiatric, hearing loss) and December 2022 (pseudofolliculitis barbae) rating decisions. As the RO (the agency of original jurisdiction, or AOJ) has already addressed this evidence in the first instance, waiver over AOJ jurisdiction with regard to the above evidence is unnecessary at this time. 38 U.S.C. § 7105(e) (2018). New and Material Evidence 1. Whether new and material evidence has been received sufficient to reopen the previously denied claim of service connection for a low back disability. After a decision becomes final, a claimant must present?new?and?material?evidence to reopen the previously denied claim.?38 U.S.C. § 5108;?38 C.F.R.§ 3.156(a). New?evidence is evidence not previously submitted to agency decision makers. Material?evidence, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence cannot be cumulative or redundant of the evidence of record at the time of the last prior final denial and must raise a reasonable probability of the substantiating the claim.?38 C.F.R. § 3.156(a). The provisions of 38 U.S.C. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-83 (1996). Newly submitted evidence is generally presumed to be credible for the purposes of reopening a claim. Justus v. Principi,?3 Vet. App. 510, 513 (1992). New and material evidence is not required for each previously unproven element of a claim. Shade v. Shinseki,?24 Vet. App. 110, 120?(2010). The threshold for determining whether evidence raises a reasonable possibility of substantiating a claim is low.?Id. at 117-18. In April 2004, VA received the Veteran's original claim for service connection for a low back disability. In an October 2004 rating decision, the RO denied the claim because the Veteran did not have a "permanent residual or chronic disability subject to service connection." In essence, therefore, the RO denied the claim because the evidence did not show that the Veteran had a current low back disability. The Veteran received notification of the decision in October 2004, but did not submit an NOD or new and material evidence within one year of notification of the decision. Therefore, the April 2004 rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 19.52, 20.1103. In February 2018, VA received a new claim for service connection for a low back disability. In the March 2018 rating decision, the RO denied reopening of the claim because new and material evidence had not been received. The evidence of record at the time of the October 2004 rating decision included service treatment records (STRs) and VA treatment records. The evidence received since the October 2004 rating decision includes additional VA treatment records, Social Security Administration (SSA) records, and the January 2023 Board hearing transcript. The evidence received after the October 2004 rating decision relates to an unestablished fact necessary to substantiate the claim and is not cumulative or redundant. Specifically, a September 16, 2016 VA x-ray confirms that the Veteran's lumbar diagnosis includes "moderate" degenerative joint disease of the lumbar spine. Furthermore, during the January 2023 Board hearing, the Veteran testified that he had experienced low back pain ever since injuring his back during service. This evidence, taken together with the evidence previously of record, is new and material and therefore the previously denied claim of service connection for a low back disability, to this extent only, is reopened. The reopened claim of service connection is addressed in the Remand section below. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.?38?U.S.C. §§?1110, 1131, 5107;?38?C.F.R. §?3.303.? The three-element test for service connection requires evidence of: (1)?a current disability; (2)?in-service incurrence or aggravation of a?disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury.?Shedden?v.?Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 2. Entitlement to service connection for pseudofolliculitis barbae. The Veteran contends that his pseudofolliculitis barbae had onset during service due to being required to shave frequently for the first time; he has reported continuity of pseudofolliculitis barbae symptoms since service. A March 2021 VA skin examination confirmed a diagnosis of pseudofolliculitis barbae. In this case, the evidence is at least evenly balanced as to whether the pseudofolliculitis barbae was incurred during service. During the January 2023 Board hearing, the Veteran reported that his pseudofolliculitis barbae started in 1982 when he was required to shave daily for the first time. See Tr. at 15. Consistent with the Veteran's statements, STRs from August 6, 1982 onward confirm that the Veteran received shaving profiles on numerous occasions, with multiple profiles in 1987 and 1988 in addition to the profile noted above. Moreover, STRs confirm that he sought treatment for flares of pseudofolliculitis barbae symptoms in 1982, 1983, 1987, and 1988. See, e.g., STRs dated October 29, 1982, March 4, 1983, March 18, 1987, and July 7, 1988. Given the above, there is no reason to doubt the Veteran's credible statements regarding onset of pseudofolliculitis barbae symptoms during service. Similarly, there is no reason to doubt the Veteran's credible statements as to continuity of pseudofolliculitis barbae symptoms since service. In an opinion submitted with the March 2021 VA skin examination, the March 2021 VA examiner concluded that the pseudofolliculitis barbae was at least as likely as not incurred in or caused by an in-service injury, event or illness. The examiner reasoned that there were "multiple in-service evaluations, treatments, and shaving profiles/extension due to pseudofolliculitis barbae, with an in-service examination showing "multiple eruptions due to shaving." Regarding the probative value of the above opinion, the examiner reviewed the claims file and supported the opinion with a reasoned analysis of pertinent medical evidence. Accordingly, the opinion is afforded significant probative value as to nexus. Given the above, the evidence is at least evenly balanced as to whether the Veteran's pseudofolliculitis barbae was incurred during service. Accordingly, resolving reasonable doubt in the Veteran's favor, service connection for pseudofolliculitis barbae is warranted. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with depressed mood (claimed as insomnia) for the period prior to July 20, 2020. 4. Entitlement to service connection for a separate sleep disorder. As noted in the "Introduction," the issue of service connection for an acquired psychiatric disorder, claimed as insomnia, for the period on appeal prior to July 20, 2020 remains on appeal, and necessarily includes adjustment disorder with depressed mood prior to July 20, 2020. A September 2020 VA psychiatric examination confirmed a diagnosis of adjustment disorder with depressed mood; the September 2020 VA examiner provided no other psychiatric diagnoses. Per the September 2020 VA psychiatric examination, the Veteran reported symptoms of depression and anxiety dating back to service. Similarly, during the January 2023 Board hearing, the Veteran reported insomnia with onset during basic training. Tr. at 12. An August 25, 2016 VA primary care E & M note provides the first medical evidence of depression symptoms. A December 7, 2018 VA mental health consult indicates that the Veteran reported "severe" depression and anxiety at that time. A subsequent January 18, 2019 VA PCC behavioral health note indicates that the Veteran received a diagnosis of major depressive disorder with psychotic features from a VA psychiatrist. Given the above, resolving all reasonable doubt in the Veteran's favor, the evidence suggests that the adjustment disorder with depression was factually ascertainable as of the February 5, 2018 claim for service connection for insomnia. In an opinion associated with the September 2020 VA psychiatric examination report, the September 2020 VA psychiatric examiner opined that the Veteran's adjustment disorder with depressed mood was at least as likely as not proximately due to the service-connected sinusitis with sinus headaches - for which service connection is effective from February 5, 2018 (also the date of claim for service connection for insomnia). The examiner noted that the Veteran's reported symptoms were consistent with the diagnostic criteria for adjustment disorder with depressed mood, "stemming from pain described as chronic and coming from arthritis in feet, wrists, knees, shin, legs, neck, lower back, along with sinus and migraine headaches, and the physical limitations that result." Finally, the examiner noted that "sinus headaches were identified by the veteran as contributing to his stress leading to feeling depressed." This opinion was supported by interview with the Veteran and review of the claims file and includes a fully articulated opinion supported by a reasoned analysis of pertinent evidence. As such, the September 2020 VA opinion is afforded significant probative value as to nexus. Furthermore, based on the September 2020 VA opinion, in the September 2020 rating decision, the RO granted service connection for adjustment disorder with depressed mood. Given the above, the evidence clearly shows a nexus between the adjustment disorder with depressed mood and the service-connected sinusitis with sinus headaches, and that the adjustment disorder with depressed mood was factually ascertainable prior to July 20, 2020, to include as of February 5, 2018. Accordingly, service connection for adjustment disorder with depressed mood, to include the symptom of insomnia, prior to July 20, 2020 is warranted. However, with regard to psychiatric disorders other than adjustment disorder with depressed mood, to include the diagnosis of major depressive disorder with psychotic features made by VA treatment providers, there is no indication that the major depressive disorder with psychotic features is manifested by symptoms that are separate and distinct from the service-connected adjustment disorder with depressed mood, and, while the Veteran reports symptoms of insomnia, the September 2020 VA psychiatric examination report indicates that chronic sleep impairment is a symptom associated with the adjustment disorder with depressed mood. In general, only one rating is available for psychiatric symptoms under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. There is no indication that any symptoms of major depressive disorder with psychotic features or insomnia would be distinguishable from the service-connected adjustment disorder with depressed mood. Likewise, there is no indication in the record that the Veteran has a separately diagnosed sleep disorder to account for his chronic sleep impairment and insomnia symptoms, and the Veteran has not asserted such. At the Board hearing, the Veteran testified that he wanted to continue his claim of service connection for insomnia, even though the insomnia had been attributed to a service-connected mental health disorder with an effective date of July 20, 2020. In this decision, the Board considered the Veteran's insomnia claim, and granted service connection for the adjustment disorder with depressed mood for the period on appeal prior to July 20, 2020. In essence, the Board assigned an earlier effective date for service connection to account for the Veteran's claimed symptoms of insomnia and chronic sleep impairment. The record does not show the presence of another diagnosed sleep disorder and therefore service connection for a separate sleep disorder is not warranted. The Veteran has consistently complained of insomnia, trouble sleeping, and the like. His claim has been considered based on his claimed symptoms, and the VA medical evidence persuasively shows that the Veteran's sleep disturbance, described as chronic sleep impairment, insomnia, are attributable to the service-connected psychiatric disorder. As the evidence persuasively weighs against the finding that the Veteran has a separate sleep disorder with symptoms not attributable to, and/or separate and distinct from, the service-connected acquired psychiatric disorder, a separate grant of service connection is not warranted, and the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107 (b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). REASONS FOR REMAND 1. Entitlement to service connection for a low back disability, to include degenerative joint disease of the lumbar spine and lumbar spondylosis. 2. Entitlement to service connection for a neurological disability associated with the sciatic nerve. The Veteran has not received a VA examination for his low back disability. VA must provide an examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran contends that his back disability is due to "wear and tear" during service. Tr. at 4. During the January 2023 Board hearing, he testified that he experienced low back pain throughout service and sought treatment from in-service treatment providers. Furthermore, he asserts that he has experienced low back pain ever since injuring his back during service. Finally, he also contends that he has developed sciatic radiculopathy secondary to his low back disability. As noted in the "New and Material Evidence" section above, a September 16, 2016 VA x-ray showed "moderate" degenerative joint disease of the lumbar spine with "severe" disc narrowing. He has also described "left sided body numbness and tingling," as described in a December 13, 2016 non-VA note associated with VA treatment records. The Veteran's DD Form 214s show that the Veteran had military occupational specialties (MOSs) of equipment records and parts specialist for the period of service from July 1982 to July 1985 and petroleum supply specialist for the period of service from December 1985 to August 1990. Accordingly, as these MOSs could potentially be consistent with duties involving repeated heavy lifting, the Veteran's statements during the January 2023 Board hearing are could be consistent with the circumstances of his service. STRs are replete with complaints of and treatment for low back pain. The Veteran first sought treatment for low back pain on August 7, 1982 after injuring his back while lifting a trash can on the previous day. He sought treatment for low back pain two more times in 1982 - on August 24 and September 1, 1982. On March 25, 1983, he again sought treatment for low back pain after falling on his back 11 days prior to the visit. He sought treatment for low back pain again on June 11 and November 21, 1983, with a diagnosis of a back sprain included in the November 1983 note. A November 19, 1984 STR indicates that the Veteran suffered back trauma within the past 72 hours. On a June 15, 1985 Report of Medical History, the Veteran reported recurrent back pain "sometimes." A May 16, 1988 STR provides the next evidence of treatment for low back pain during service. A subsequent January 16, 1989 STR indicates that the Veteran injured his back while lifting heavy objects. A December 15, 1989 STR documented "sudden onset of low back pain"; at the time of this note, the Veteran stated that he had had back pain throughout his military service and that the current flare-up of pain was the worst he had ever had. He reported incurring the injury during a basketball game. An x-ray dated the same day revealed minimal levoscoliosis but no other abnormalities. Here, there is evidence of a current low back disability, ample STR evidence of low back injuries and treatment during service, an indication that the current low back disability may be related to the in-service low back injuries, and insufficient evidence to decide the claim. Accordingly, remand is warranted for an initial VA examination and opinion for the low back disability. In the examination report, the examiner must also describe any signs and symptoms due to sciatic radiculopathy. Finally, review of the claims file suggests that the Veteran's separation examination and Report of Medical History for his second period of active duty from December 1985 to August 1990 - if completed - have not yet been associated with the file. Accordingly, on remand, the RO should attempt to locate a separation examination and/or Report of Medical History for the Veteran's second period of active duty. 3. Entitlement to service connection for a cervical spine disability, including degenerative joint disease of the cervical spine. The Veteran has not received a VA examination for his claim of service connection for a cervical spine disability. The Veteran has a current diagnosis of degenerative joint disease of the cervical spine, as shown by a September 16, 2016 VA x-ray. During the January 2023 Board hearing, the Veteran testified that he experienced neck pain on and off throughout and following service. See Tr. at 18-19. While STRs do not specifically note treatment for pain associated with the cervical spine, as noted in the preceding section regarding the low back disability, it is nonetheless plausible that the Veteran may have also experienced neck pain during service. In this regard, the June 26, 1985 Report of Medical History, in which the Veteran reported recurrent back pain, did not distinguish between the lumbar and cervical spines. Furthermore, the Veteran's report of wear and tear during service during the January 2023 Board hearing was not specifically limited to the low back; as noted above, the Veteran's MOSs are consistent with duties involving repeated heavy lifting during service. As there is insufficient competent medical evidence to decide the claim, remand is warranted for an initial VA examination for the cervical spine disability. 4. Entitlement to service connection for a bilateral foot/ankle disability. At the outset, during the January 2023 Board hearing, the Veteran's testimony concerned both his feet and his ankles. During the hearing, he stated that he had braces for both ankles. An August 28, 2019 VA orthotics prosthetics consult confirms that the Veteran has been issued bilateral ankle braces by VA providers. Finally, the Veteran believes that he may have experienced frostbite of his feet during service in Germany. Given the above, the claim for service connection for a bilateral foot disability (originally claimed as service connection for plantar fasciitis, pes planus, spurs and bursitis) has been expanded to include all diagnosed foot and ankle disabilities and any frostbite residuals. See Clemons, 23 Vet. App. at 1. The Veteran has not received a VA examination for his claimed bilateral foot/ankle disability. During the January 2023 Board hearing, the Veteran testified that he experienced foot pain as early as 1982 due to performing long road marches with a heavy backpack. See Tr. at 7. He also testified that he was treated for frostbite in approximately 1984. See id. at 10. STRs confirm that the Veteran sought treatment for pain in both the right and left feet during service. First, a June 15, 1985 STR shows that the Veteran sought treatment for pain in the right heel and in the second and third toes metatarsal heads. On the June 26, 1985 Report of Medical History, he reported foot trouble. He again sought treatment for right heel and second and third toe metatarsal pain on January 15, 1986 and received a differential diagnosis of "spurs vs. bursitis vs. metatarsalgia." Finally, an October 31, 1986 STR indicates that the Veteran injured his "foot" while running; the STR noted a diagnosis of a twisted ankle. Furthermore, personnel records indicate that the Veteran served in Germany from June 1987 to June 1989 (as well as Korea from January 1983 to January 1984). Notably, a March 26, 1990 STR describes a recurrent rash accompanied by joint pains; it is unclear where the rash and joint pain were located. As there is insufficient competent medical evidence to decide the claim, remand is warranted for an initial VA examination for the bilateral foot/ankle disability. 5. Entitlement to an initial compensable disability rating for the service-connected bilateral hearing loss disability. The Veteran most recently received a VA audiological examination in July 2020. However, the July 2020 VA examiner concluded that the audiological testing during the examination was invalid for rating purposes. In support, the examiner noted that there was "poor inter-test reliability" because the "Veteran had to be prompted to respond during [speech recognition threshold] testing,' during which the Veteran gave "[h]alf word responses." Accordingly, the "Veteran's responses to behavioral audiometry testing were unreliable and invalid" in both right and left ears. Regarding puretone testing, the examiner stated that Veteran's responses "were unreliable and invalid" bilaterally," with thresholds that were "supra-threshold significantly when compared to speech recognition thresholds." Notably, however, approximately two-and-a-half years prior to the July 2020 VA audiological examination, a February 2018 VA audiological examiner was able to perform puretone and speech recognition threshold testing with no apparent difficulty. Given the above, it is unclear whether the Veteran's hearing acuity is truly beyond the capabilities of audiological testing, and remand is warranted for a new VA audiological examination that includes puretone and speech threshold testing results (or a reasoned explanation of why such testing is invalid for rating purposes). In remanding this matter, no finding is made, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's or any third party's credibility nor any lack thereof should be presumed in this remand unless otherwise stated. The matters are REMANDED for the following action: 1. Attempt to obtain any outstanding STRs, including a separation examination and/or Report of Medical History dated near the Veteran's August 1990 separation from service. All such attempts should be documented in the claims file, including a request to the Veteran to determine if he has a copy of these records. If the RO is unable to locate the requested records, it should prepare a formal finding of unavailability in this regard. 2. After the above development has been completed, schedule the Veteran for a VA examination to determine the current nature and likely etiology of his low back disability and claimed associated neurological impairment of the lower extremities. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner must indicate that the claims file was reviewed in the examination report. A complete rationale for all opinions must be provided. Applying general medical principles and the examiner's own expertise, the examiner should state whether it is at least as likely as not (the evidence is evenly balanced, or nearly equal, if not higher) that any low back disability, to include degenerative joint disease of the lumbar spine, was incurred in service or manifested to a degree of 10 percent or more within one year of separation; or is otherwise related to service. The examiner should also describe any signs and symptoms due to sciatic radiculopathy in the examination report. The examiner is referred to the Veteran's contention that his low back disability is due to wear and tear during service. In this regard, it is conceded that the Veteran's in-service MOSs of equipment records and parts specialist and petroleum supply specialist could have involved repetitive heavy lifting, and the examiner should obtain a full recorded history from the Veteran in that regard. The examiner is also referred to the numerous STRs regarding report of and treatment for low back pain, including STRs dated the following: August 7 and 24 and September 1,1982; June 11 and November 21, 1983; November 19, 1984; June 15, 1985 (Report of Medial History); May 16, 1988; and December 15, 1989. Finally, the examiner is referred to the Veteran's contention that he has experienced low back pain ever since his period of service. In providing the request opinion, please discuss the significance, if any, of the above evidence in forming the opinion. 3. Schedule the Veteran for a VA examination to determine the current nature and likely etiology of his cervical spine disability. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner must indicate that the claims file was reviewed in the examination report. A complete rationale for all opinions must be provided. Applying general medical principles and the examiner's own expertise, the examiner should state whether it is at least as likely as not that any cervical spine disability, to include degenerative joint disease of the cervical spine, was incurred in service or manifested to a degree of 10 percent or more within one year of separation; or is otherwise related to service. The examiner is referred to the Veteran's contention that his cervical spine disability is due to wear and tear during service. In this regard, it is conceded that the Veteran's in-service MOSs of equipment records and parts specialist and petroleum supply specialist could have involved repetitive heavy lifting. In providing the request opinion, please discuss the significance, if any, of the above evidence in forming the opinion. 4. Schedule the Veteran for a VA examination to determine the current nature and likely etiology of his foot/ankle disability. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner must indicate that the claims file was reviewed in the examination report. A complete rationale for all opinions must be provided. The examiner should complete disability benefits questionnaires for the feet, ankles, and the claimed cold injury residuals and describe all pertinent signs and symptoms. Applying general medical principles and the examiner's own expertise, the examiner should state whether it is at least as likely as not (the likelihood is approximately evenly balanced or nearly equal, if not higher) that any foot/ankle disability was incurred in or is related to service. The examiner is referred to the Veteran's contention that his foot/ankle disabilities are related to regular performance of road marches while carrying a 100-pound backpack and/or due to frostbite during service in Germany. The examiner also referred to the STRs of record documenting pain in the right heel, right second and third toe metatarsals, and left ankle, including STRs dated the following: June 15, 1985; the June 26, 1985 (Report of Medical History); January 15, 1986; and October 31, 1986. In providing the request opinion, please discuss the significance, if any, of the above evidence. 5. Schedule the Veteran for an audiological examination to determine the current severity of his service-connected bilateral hearing loss. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. If the examiner finds that the audiometric test results from the examination are unreliable and/or invalid (as did the July 2020 audiologist), the examiner should state whether it would be possible to obtain accurate audiometric results, and if not, explain the basis for this conclusion. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Small, Attorney Advisor 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.