Citation Nr: A25001663 Decision Date: 01/07/25 Archive Date: 01/07/25 DOCKET NO. 230109-312293 DATE: January 7, 2025 ORDER Entitlement to service connection for a right wrist condition, based on aggravation of a pre-existing condition, is denied. Entitlement to service connection for bilateral hearing loss is denied. The reduction of the Veteran's service-connected generalized anxiety disorder with other specified depressive disorder from 50 percent disabling to 30 percent disabling, effective September 28, 2022, was improper and the 50 percent rating is restored. REMANDED Entitlement to service connection for erectile dysfunction, claimed as a penile condition, is remanded. Entitlement to service connection for migraines, to include on a secondary basis, is remanded. Entitlement to service connection for a right knee condition, to include on a secondary basis, is remanded. Entitlement to service connection for a left knee condition, to include on a secondary basis, is remanded. Entitlement to an initial disability rating in excess of 50 percent for the Veteran's service-connected generalized anxiety disorder with other specified depressive disorder, is remanded. FINDINGS OF FACT 1. The evidence of record persuasively weighs against finding that pre-existing right wrist condition increased in severity during or due to active service. 2. The evidence of record persuasively shows that the Veteran does not currently have bilateral hearing loss for VA purposes. 3. The evidence of record at the time of the January 2023 rating decision which reduced the Veteran's disability rating did not establish improvement in the Veteran's ability to function under the ordinary conditions of life and work. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for a right wrist condition, based on aggravation of a pre-existing condition, have not been met. 38 U.S.C. §§ 1110, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for establishing entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.385 3. The reduction of the Veteran's service-connected generalized anxiety disorder with other specified depressive disorder from 50 percent disabling to 30 percent disabling was improper and the 50 percent rating is restored. 38 U.S.C. §§ 1155, 5107(b), 5112(b)(5); 38 C.F.R. §§ 3.105, 3.343, 3.344, 4.1-4.14, 4.71a, Diagnostic Code (DC) 9400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from June 2016 to June 2021. These matters come before the Board of Veterans' Appeals (Board) on appeal from June 2022, August 2022, September 2022, and January 2023 rating decisions from a Department of Veterans Affairs (VA) Regional Office (RO). In January 2023, the Veteran disagreed with the above-noted rating decision and filed a VA Form 10182 (Decision Review Request: Board Appeal (Notice of Disagreement)). The Veteran selected the Direct Review Docket by submitting notice of disagreement under the appeals Modernization Act (AMA). 38 C.F.R. § 19.2(d). Accordingly, based on the Veteran's selection of the Direct Review option, the Board is limited to review of the evidence in the record up and until the dates of notification of the rating decisions for the issues on appeal. See 38 C.F.R. §§ 3.2601, 20.301. If evidence was associated with the claims file during a period of time when additional evidence was not allowed, the Board has not considered it in its decision on the above claim. 38 C.F.R. § 20.300. If the Veteran would like VA to consider any evidence that was added to the claims file that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. Regarding the erectile dysfunction disability claim, the Board notes that the Veteran's initial service connection claim was for a penile condition and the RO denied the claim as entitlement to service connection for a penile condition. However, in Clemons v. Shinseki, the United States Court of Appeals for Veteran's Claims (Court) held that, in determining the scope of a claim, the Board must consider the claimant's description of the claim; symptoms described; and the information submitted or developed in support of the claim. 23 Vet. App. 1, 5 (2009). In light of the Court's decision in Clemons, and the medical evidence of record, the Board has re-characterized the issue on appeal as entitlement to service connection for erectile dysfunction, claimed as a penile condition. Finally, as an initial matter, the Board will address the reduction and increased rating claims for the Veteran's psychiatric condition. Generally, an appeal regarding the reduction of a rating must address only the propriety of the reduction, and not whether the veteran is entitled to a higher rating. Dofflemyer v. Derwinski, 2 Vet. App. 277, 279-80 (1992). However, when filing a claim with VA, claimants are presumed to be seeking the maximum available benefit for their disability. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In situations where the reduction stems from an original claim for a higher rating, the appeal may encompass not only the propriety of the reduction, but also the underlying claim for a higher rating. Here, the reduction of the Veteran's psychiatric disability stemmed from the Veteran's September 2022 claim for increase. See September 2022 VA 21-526EZ, Fully Developed Claim. Therefore, the Board also has jurisdiction over the increased rating claim, and it is addressed in the Remand section below. Service Connection-Legal Criteria Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A veteran will be considered to have been in sound condition when examined and accepted for service, except as to disorders noted on entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Only such conditions as are recorded in the examination reports are to be considered as "noted." See Paulson v. Brown, 7 Vet. App. 466, 470 (1995). A pre-existing injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). This standard is further explained in 38 C.F.R. § 3.306(b), which provides that clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service condition underwent an increase in severity during service. That notwithstanding, aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). In other words, the presumption of aggravation only arises "where the pre-service disability underwent an increase in severity during service." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991). If the presumption of aggravation arises under 38 U.S.C. § 1153, then the burden shifts from the Veteran to the government to rebut by clear and unmistakable evidence the pre-existing condition was not aggravated during service, or by establishing that any increase in disability is due to the natural progression of the pre-existing condition. 38 U.S.C. § 1153; 38 C.F.R. § 3.306; Cotant v. Principi, 17 Vet. App. 117, 131 (2003); VAOPGCPREC 3-03, 69 Fed. Reg. 29178 (2004); see also Wagner and Hunt, supra. In deciding a claim based on aggravation, the question turns on whether there has been any measurable worsening of the condition during service, and then on whether such worsening constitutes an increase in disability. Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). Temporary or intermittent flare ups of a pre-existing condition during service are not sufficient to be considered aggravation unless the underlying condition, as contrasted to symptoms, has worsened. Crowe v. Brown, 7 Vet. App. 238, 247-48 (1994); Hunt v. Derwinski, 1 Vet. App. at 296-97. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the weight of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. To deny a claim on its merits, the weight of the evidence must persuasively stand against a finding that the evidence is in "approximate balance" or "nearly equal" to the evidence that supports the claim. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). The Board notes that it has reviewed all of the evidence of record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, with regard to the Veteran's claims. Right Wrist-Analysis The Veteran seeks entitlement to service connection for his claimed right wrist condition. For the reasons below, the Board finds that the evidence of record is persuasively against finding that the Veteran is entitled to service connection for his claimed right wrist condition. As such, the Veteran's claim is denied. The Veteran's February 2016 medical examination prior to entry into service shows that the Veteran was suffering from a pre-existing right forearm condition. It was noted that the Veteran underwent an ORIF due to right arm radius and ulna fractures with two plates and ten screws inserted as permanent hardware. Hence, the Veteran cannot be presumed sound concerning his right wrist. 38 U.S.C. § 1111. When a defect, infirmity, or disorder is noted on the enlistment examination, the only benefits that can be awarded are for aggravation pursuant to 38 U.S.C. § 1153 and 38 C.F.R. § 3.306. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). A pre-existing injury or disease will be presumed to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability was due to the natural progress of the disease. 38 C.F.R. § 3.306(a). In such claims, the evidence of record must simply show that there was an increase in disability during service to trigger the presumption of aggravation; the burden then shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." See Wagner, 370 F.3d at 1096 (citing 38 U.S.C. § 1153). This requires the government to show by clear and unmistakable evidence that any increase in disability was due to the natural progress of the condition. See Cotant v. Principi, 17 Vet. App. 116, 130-32 (2003); see also 38 C.F.R. § 3.306(b). After a review of the relevant evidence, the Board finds that the evidence of record does not tend to show that the Veteran's existing right wrist condition increased in severity during service. Temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted with symptoms, has worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993). With this in mind, the Veteran's relevant service treatment records (STRs) only contain two complaints of acute right wrist pain, one following a skateboard accident in June 2018 where he fell on his wrist, and one in October 2018 for wrist pain after lifting an ammo can. No further treatment or complaints of pain are noted throughout the rest of the Veteran's service. In June 2022, the Veteran underwent a VA Wrist Conditions examination. The examiner confirmed the diagnosis of right wrist status post ORIF with hardware placement. During the examination the Veteran noted that he fractured his wrist prior to joining the Marine Corps and underwent an ORIF with hardware. He noted that he noticed his right hand and wrist is painful, stiff, and weaker when compared to his left wrist. He further noted that he has not been treated for this condition since separation, but that he still works as a mechanic. The Veteran's current symptoms included pain with flare-ups once a week with aggravating factors including twisting, pushing, and pulling. The Veteran alleviates his symptoms with compression wraps, ice, Tylenol, ibuprofen, icy hot, and rest. The Veteran noted that he has had to miss 4-5 days of work due to his right wrist pain. The VA examiner opined that the Veteran's right wrist condition clearly and unmistakably pre-existed the Veteran's time in service and was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner's rationale provided that while temporary aggravation of the Veteran's right wrist was possible, there was no evidence to suggest a permanent aggravation of the pre-existing status post ORIF. The examiner noted that a thorough review of the medical literature fails to support that the pre-existing condition was permanently aggravated by service. The examiner continued that the Veteran served five years in the Marine Corps and was seen for his right wrist only on two occasions: once following a skateboard accident, and once after lifting an ammo can. The examiner noted that x-rays were performed following the in-service skateboard injury and were negative for any osseus injury or chronic degenerative changes. The examiner noted that the Veteran was not seen for treatment following 2018 for his wrist condition. There are no documented STRs for wrist pain in the remaining 3 years of the Veteran's active service, or since separation. The examiner noted that the Veteran still works in the same occupation as a mechanic, and that recent x-rays have demonstrated stable post-surgical changes with no evidence of any osseus or other degenerative changes. The examiner concluded that there is no persuasive evidence to suggest that the Veteran's right wrist condition was aggravated beyond its natural progression by his active service. The Board finds that the above evidence does not tend to show that there was an increase in disability during service to trigger the presumption of aggravation. The Board is mindful of the Veteran's assertions regarding his right wrist condition and the onset of his present right wrist condition during active-duty service. However, since the issue on appeal is medically complex, rather than simple, there must be competent medical evidence supporting the notion of aggravation, as opposed to intermittent, self-limited flare-ups of the pre-existing disability. Independent medical evidence generally is needed to support a finding that the pre-existing disability increased in severity during service beyond its natural progression. See Paulson v. Brown, 7 Vet. App. 466, 468 (1995). The Board finds the June 2022 VA examination and opinion on which it has relied in making this decision to be both adequate and probative. The examination report included a recitation of the Veteran's medical history, including that related by the Veteran. The examination report and opinion provided sufficient information to allow the Board to make an informed decision, and it contained a reasoned explanation supporting the examiner's conclusions. The Board acknowledges the Veteran's belief that his pre-existing right wrist condition was aggravated by his active service. However, the Board finds that opining on whether an existing wrist disorder was aggravated, especially years after the fact, requires medical training. See Kahana v. Shinseki, 24. Vet. App. 428 (2011). There is no evidence that the Veteran has medical training. Hence, his opinion on the issue is not competent and lacks weight. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also 38 C.F.R. § 3.159(a). Based on the evidence discussed above, the Board finds that the evidence is persuasively against the claim for aggravation of pre-existing right wrist condition. In reaching this conclusion, the Board has considered and applied the benefit-of-the-doubt rule. "When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant." 38 U.S.C. § 5107(b). "Evidence is not in 'approximate balance' or 'nearly equal,' and therefore the benefit-of-the-doubt rule does not apply, when the evidence persuasively favors one side or the other." Lynch v. McDonough, 21 F. 4th 776 (Fed. Cir. 2021). In this case, the evidence persuasively favors a finding that the Veteran's right wrist condition was not aggravated beyond its natural progression by his time in service. Thus, the benefit-of-the-doubt rule does not change the outcome on this issue. As such, the Veteran's claim for service connection is denied. Bilateral Hearing Loss-Legal Criteria Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests sensorineural hearing loss or tinnitus within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as opposed to merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service (or during any applicable presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The term "chronic disease" refers to those diseases, such as hearing loss, listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. See Palczewski v. Nicholson, 21 Vet. App. 174, 178-80 (2007) (specifically upholding the validity of 38 C.F.R. § 3.385 to define hearing loss for VA compensation purposes). However, the absence of in-service evidence of hearing loss is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability, i.e., one meeting the requirements of 38 C.F.R. § 3.385, as noted above, and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Bilateral Hearing Loss-Analysis The Board finds that the probative evidence of record does not document that the Veteran has a current diagnosis of any hearing loss disability for VA purposes. As such, service connection is not warranted on a direct or presumptive basis for the claimed disability. The Board has thoroughly reviewed the Veteran's medical records. The Board notes that the Veteran has conceded exposure to in-service acoustic trauma. See June 2022 Rating Decision. This is a favorable finding for the Veteran, by which the Board is bound. The Veteran's in-service and post-service treatment records do not contain any information which differs significantly from, or is worse than, the below cited VA examination. The Veteran was provided with a March 2022 VA Hearing Loss examination. Pertinently, the audiological examination revealed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 AVG (1000-4000) RIGHT 10 10 15 10 5 10 LEFT 10 20 25 10 5 15 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 96 percent in the left ear. As noted above, for the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran's hearing loss does not meet these requirements. The Veteran's treatment notes also do not indicate that the Veteran has a current diagnosis of hearing loss for VA purposes. Based on the above, the Board does not find evidence of any hearing loss disability for VA purposes at any time during the pendency of the appeal. Thus, to the extent the Veteran asserts that he has a current hearing loss condition for VA purposes, such statements are inconsistent with the medical evidence of record that does not document any relevant diagnosis at any time during the pendency of the appeal. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Therefore, notwithstanding his assertion that he has a bilateral hearing loss disability, the audiometric evidence reflects that the Veteran does not have a current hearing loss disability for VA purposes. See Palczewski, supra. As the evidence establishes that the Veteran does not have a current disability for VA purposes concerning his claimed bilateral hearing loss and has not had such disability at any point during the pendency of the appeal, the evidence is persuasively against the claim of entitlement to service connection. There is no reasonable doubt to be resolved, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. 49. Reduction-Generalized Anxiety Disorder with Other Specified Depressive Disorder The Veteran contends the reduction of the disability rating for his generalized anxiety disorder with other specified depressive disorder from 50 percent to 30 percent, effective September 28, 2022, was not proper and seeks to have the 50 percent rating restored. For the reasons below, the Board agrees, and finds a restoration of the 50 percent disability rating is warranted. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. A veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. 38 C.F.R. § 3.344. The United States Court of Appeals for Veterans Claims has consistently held that when a disability rating is reduced without following the applicable regulations, the reduction is void ab initio. See Greyzck v. West, 12 Vet. App. 288, 292 (1999). 38 C.F.R. § 3.105(e) sets forth procedural requirements where a reduction in the rating of a service-connected disability is considered warranted, and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made. The Veteran must be notified of the contemplated action, furnished detailed reasons therefore, and given 60 days for the presentation of additional evidence. If additional evidence is not received within that period, final rating action may be taken, and the award will be reduced effective the last day of the month in which the 60-day period from the notice to the Veteran of the final rating action expires. The Veteran's rating was reduced in a January 2023 rating decision, however, the reduction in the Veteran's rating did not result in a reduction of compensation payments currently being made to the Veteran. Given the above, the Board finds that the RO complied with the requirements of 38 C.F.R. § 3.105(e). The Board next notes that the circumstances under which an evaluation may be reduced are specifically limited and carefully circumscribed by regulations promulgated by the Secretary of VA. Dofflemyer v. Derwinski, 2 Vet. App. 277, 280 (1992). VA will handle cases affected by change of medical findings or diagnosis so as to produce the greatest degree of stability of disability ratings consistent with the laws and VA regulations governing disability compensation and pension. Where an evaluation has been in effect for less than five years, the service-connected disorder has not become stabilized, and/or the disability is likely to improve, an evaluation may be reduced based upon "reexaminations disclosing improvement, physical or mental," of the disability. 38 C.F.R. § 3.344(c). The United States Court of Appeals for Veterans' Claims (Court) has clarified that: Thus, in any rating-reduction case not only must it be determined that an improvement in a disability has actually occurred but also that that improvement actually reflects an improvement in the Veteran's ability to function under the ordinary conditions of life and work. Brown (Kevin) v. Brown, 5 Vet. App. 413, 421 (1993). In a precedential decision, the Court held that when the Board, in reducing a non-protected rating, fails to conduct the analysis required by Brown as to whether the improvement in the disability reflects an actual improvement in the ability to function under the ordinary conditions of life and work, the proper remedy is reversal of the Board's decision and reinstatement of the disability rating. Stern v. McDonough, 34 Vet. App. 51 (2021). Additionally, in determining whether a reduction was proper, the Board must focus upon evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of rating whether the condition had actually improved. Dofflemyer, 2 Vet. App. 281-282. It should be emphasized, however, that such after-the-fact evidence may not be used to justify an improper reduction. In the present case, an August 2022 rating decision granted service connection and entitlement to a 50 percent rating for the Veteran's psychiatric condition effective June 20, 2021. In September 2022 the Veteran filed a VA Form 21-526EZ seeking entitlement to an increased rating for his psychiatric condition. In September 2022, the Veteran was afforded a VA examination. Based upon that examination report, the RO concluded that the Veteran did not meet the criteria for a 50 percent rating and reduced the Veteran's rating to a 30 percent rating effective September 28, 2022. The January 2023 rating decision which effectuated the reduction merely concluded that the Veteran's symptoms did not meet the criteria for the higher rating. This is not the proper standard for reducing a Veteran's rating. For a rating in effect for fewer than 5 years, the evidence must show that there was an actual improvement in the ability to function under the ordinary conditions of life and work. See Brown, 5 Vet. App. at 421. The January 2023 rating decision relies on the September 2022 VA examination for the rating reduction. However, this examination noted that the Veteran still continuously sought treatment for his mental health disability; experienced anxiety and depression; and struggles with interpersonal relationships. The evidence of record does not indicate that there was improvement in the Veteran's ability to function under the ordinary conditions of life and work. VA examination reports and treatment records at the time of the January 2023 reduction indicate on-going symptoms. The examination reports and treatment records do not indicate that the symptoms had improved under the ordinary conditions of life and work. As there was no evidence of sustained improvement, the reduction was not proper, and the 50 percent rating is restored. REASONS FOR REMAND Erectile Dysfunction The Board shall remand for any pre-decisional error on the part of the AOJ to satisfy its duties under 38 U.S.C. § 5103A and may remand for correction of any other error by the AOJ in satisfying a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the appellant's claim. 38 C.F.R. § 20.802(a). As noted above, the Board has re-characterized the issue on appeal to entitlement to service connection for erectile dysfunction, claimed as a penile condition in order to more accurately reflect the Veteran's claim. In so doing, the Board notes that in his September 2022 VA Form 21-526EZ Fully developed claim form on which this claim is based, the Veteran requested service-connection for a penile condition as "the thrills of medical evacuations and speed have made my love life hard." Further, in a September 2022 lay statement, the Veteran noted that he battles depression daily, and that his "penile condition" resulted from not being able to perform sexually. Given the above, the Board finds that the low threshold of the McLendon standard has been met in this instance. Therefore, the failure to provide the Veteran with an etiological opinion regarding the etiology of his claimed condition is a pre-decisional duty to assist error, and that the Veteran's claim should be remanded in order to afford the Veteran a VA examination in order to determine the nature and etiology of his claimed penile condition. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Migraines The Board shall remand for any pre-decisional error on the part of the AOJ to satisfy its duties under 38 U.S.C. § 5103A and may remand for correction of any other error by the AOJ in satisfying a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the appellant's claim. 38 C.F.R. § 20.802(a). The Board notes that the Veteran has not been provided with a medical examination to address the etiology of his claimed migraine condition. Further, the Board notes that the January 2023 rating decision on appeal denied service connection partially due to the lack of a currently diagnosed condition. However, the Board notes that the RO obtained a September 2022 VA Mental Disorders examination wherein a VA examiner noted that the Veteran had a migraine diagnosis that was relevant to his service connected psychiatric condition. Given the above, the Board finds that the low threshold of the McLendon standard has been met in this instance. Therefore, the failure to provide the Veteran with an etiological opinion is a pre-decisional duty to assist error, and that the Veteran's claim should be remanded in order to afford the Veteran VA examinations to determine the nature and etiology of his claimed migraine condition. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Bilateral Knees. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicolson, 21 Vet. App. 303, 312 (2007). To be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). While there is a September 2022 VA medical opinion regarding the etiology of the Veteran's bilateral knee conditions, the Board finds it to be inadequate for adjudication purposes. Initially, the Board notes that the examiner did not proffer an opinion on direct service connection. The Board notes that the Veteran's STRs contain an August 2018 treatment record for knee joint pain, intermittent locking, and knee buckling. Further, the Veteran indicated in his lay statements during his VA examination that his knee condition gradually onset during service. Additionally, in proffering their opinion, regarding secondary service connection the examiner did not opine on whether the Veteran's bilateral knees were aggravated by his service-connected lumbar spine. Instead, the examiner merely noted that it was less likely than not that the Veteran's knees were due to his lumbar spine disability. Of note, secondary service connection is warranted for a current disability that is either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.301(a), (b); Allen v. Brown, 7 Vet. App. 439 (1995). As such, the Board finds that the secondary service connection opinion is inadequate because it fails to address aggravation. Atencio v. O'Rouke, 30 Vet. App. 74, 91 (2018). For these reasons, the Board finds that the failure to obtain an adequate medical opinion constitutes a pre-decisional duty to assist error. As such, the Board finds the Veteran's claim must be remanded. Generalized Anxiety Disorder with Other Specified Depressive Disorder The Board shall remand for any pre-decisional error on the part of the AOJ to satisfy its duties under 38 U.S.C. § 5103A and may remand for correction of any other error by the AOJ in satisfying a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the appellant's claim. 38 C.F.R. § 20.802(a). As stated above, the reduction of the Veteran's psychiatric disability stemmed from the Veteran's September 2022 claim for increase. See September 2022 VA 21-526EZ, Fully Developed Claim. Therefore, the Board also has jurisdiction over the increased rating claim. In light of the above finding that the reduction in the rating of the Veteran's psychiatric disability was not proper, the Board finds that remand is required for the AOJ to consider the Veteran's entitlement to an increased rating in the first instance. See Green v. McDonough, 37 Vet. App. 127 (2024) (holding that if an agency decision which post-dates the decision on appeal affects potential entitlement to a benefit and it would be prejudicial for the Board to adjudicate entitlement to that benefit in the first instance given the change in circumstances, an error exists requiring remand pursuant to 38 USC 7104(a); 20.802(a)). The matters are REMANDED for the following action: 1. Schedule the Veteran for VA examinations by an examiner(s) with sufficient expertise to address the etiology of the Veteran's claimed erectile dysfunction, migraine, and bilateral knee disabilities. The record must be made available to and be reviewed by the examiner, and any indicated studies should be performed. Following a review of the relevant records and lay statements, the examiner should state an opinion regarding the following: - Whether the Veteran's claimed migraine condition is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) etiologically related to his active-duty service. - Whether it is at least as likely as not (likelihood is at least in approximate balance or nearly equal, if not higher) that the Veteran's claimed migraine disability was due to, or aggravated by, his service-connected psychiatric disabilities, to include the medication taken in treatment thereof. - Whether the Veteran's claimed erectile dysfunction condition is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) etiologically related to his active-duty service. - Whether it is at least as likely as not (likelihood is at least in approximate balance or nearly equal, if not higher) that the Veteran's claimed erectile dysfunction disability was due to, or aggravated by, his service-connected psychiatric disabilities, to include the medication taken in treatment thereof. - Whether the Veteran's claimed bilateral knee conditions are at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) etiologically related to his active-duty service. - Whether it is at least as likely as not (likelihood is at least in approximate balance or nearly equal, if not higher) that the Veteran's claimed bilateral knee conditions were due to, or aggravated by, his service-connected disabilities, to include the medication taken in treatment thereof. The Board notes that aggravation need not be a permanent worsening of the disability. A temporary worsening of a disability may constitute aggravation. The examiner must provide a complete rationale for all proffered opinions. In this regard, the examiner must discuss and consider the Veteran's competent lay statements. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 2. Then, schedule the Veteran for an appropriate VA examination, with a qualified examiner to determine the current nature and severity of his service-connected psychiatric disabilities. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. The examiner must provide a complete rationale for all proffered opinions. If an examiner is unable to provide any required opinion, he or she should explain why. If an examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete answer as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gresham, Trevor 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.