Citation Nr: A25035689 Decision Date: 04/17/25 Archive Date: 04/17/25 DOCKET NO. 240720-458120 DATE: April 17, 2025 ORDER The appeal as to service connection for hip pain, back pain, cervical and thoracic strain, concussion with headaches, and subacromial bursitis is dismissed. Service connection for aging is denied. Service connection for hair loss is denied. Service connection for depression is denied. An initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. An initial compensable disability rating for bilateral hearing loss is denied. An initial disability rating in excess of 10 percent for tinnitus is denied. REMANDED Service connection for acne is remanded. Service connection for photophobia (claimed as a vision disability) is remanded. Service connection for a left knee disability is remanded. Service connection for a right knee disability is remanded. Service connection for a left ankle disability is remanded. Service connection for a right ankle disability is remanded. Service connection for a left hand disability is remanded. Service connection for a right hand disability is remanded. Service connection for an unknown skin growth of the left lower abdomen (claimed as a stomach area cyst) is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran did not submit a timely appeal to the Board within one year of a February 2006 Statement of the Case which last adjudicated service connection for hip pain, back pain, cervical and thoracic strain, concussion with headaches, and subacromial bursitis. 2. Aging is not considered a recognized disability by the Department of Veterans Affairs (VA). 3. The evidence of record persuasively weighs against finding that the Veteran has had hair loss at any time during or approximate to the pendency of the claim. 4. The evidence of record persuasively weighs against finding that the Veteran has had a separate and distinct disability of depression for which service connection may be established. 5. The severity, frequency, and duration of the Veteran's PTSD symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 6. The Veteran's bilateral hearing loss has been manifested by hearing acuity of no worse than Level II hearing loss in the right ear and no worse than Level I hearing loss in the left ear. 7. The Veteran's tinnitus has been assigned the maximum schedular rating throughout the entire appeal period and does not warrant an extraschedular evaluation. CONCLUSIONS OF LAW 1. Due to the untimeliness of the Veteran's appeal, which is a procedural defect, the Board will not adjudicate the merits of the service connection claims on appeal for hip pain, back pain, cervical and thoracic strain, concussion with headaches, and subacromial bursitis. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.203, 20.205. 2. The criteria for service connection for aging have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for hair loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for depression have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for an initial disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 6. The criteria for an initial compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1155, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.10, 4.85, Diagnostic Code 6100. 7. The criteria for an initial disability rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.1, 4.2, 4.3, Diagnostic Code 6260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1997 to September 2001 and from August 2012 to November 2012. As it pertains to the service connection claims for aging, hair loss, depression, acne, photophobia, bilateral knee, ankle, and hand disabilities, and an unknown skin growth, and increased rating claims for PTSD, bilateral hearing loss, and tinnitus, these matters come to the Board of Veterans' Appeals (Board) on appeal from initial February 2024 rating decisions; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. In the July 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the February 2024 rating decisions on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the February 2024 decisions cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. If the Veteran would like VA to consider any evidence that was submitted 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(s), considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. However, because the Board is remanding the claims of service connection for acne, photophobia, bilateral knee, ankle, and hand disabilities, and an unknown skin growth, any evidence the Board could not consider will be considered by VA in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii). As it pertains to the claims of service connection hip pain, back pain, cervical and thoracic strain, concussion with headaches, and subacromial bursitis, for reasons discussed below, the Board finds that dismissal is appropriate. Finally, the Board finds that entitlement to TDIU has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), as part of the Veteran's PTSD increased rating claim on appeal. 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; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). When there is an approximate 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. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. Entitlement to service connection for hip pain, back pain, cervical and thoracic strain, concussion with headaches, and subacromial bursitis. By way of history, in an August 2005 rating decision, VA denied service connection for hip pain, back pain, cervical and thoracic strain, concussion with headaches, and subacromial bursitis. The Veteran filed a timely notice of disagreement, and in February 2006, VA issued a Statement of the Case (SOC). In July 2024, the Veteran filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), identifying these issues. Here, the Veteran did not file an appeal to the Board by either a VA Form 9 under the legacy system or VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) with the February 2006 SOC until July 20, 2024, well outside the 60-day filing period. See 38 C.F.R. § 19.52; see also 38 C.F.R. § 3.2400(c)(2). Furthermore, he has not submitted good cause for failing to file an appeal within the required time period. As such, the Veteran's VA Form 10182 is untimely and constitutes a procedural defect, and the Board will not consider the merits of this appeal. 38 U.S.C. § 7105. The Board is authorized to dismiss any appeal that fails to allege an error of fact or law. 38 U.S.C. § 7105(d)(5). Accordingly, these matters are dismissed. 2. Entitlement to service connection for aging. The Veteran seeks service connection for aging. Specifically, he asserts that the rigors of service have caused him to age faster than his peers who did not serve. Aging, in and of itself, is a not a disability recognized by VA. See 38 C.F.R. Part 4, Schedule for Rating Disabilities. Accordingly, the claim for service connection for aging must be denied as it is without legal merit. Sabonis v. Brown, 6 Vet. App. 426 (1994). 3. Entitlement to service connection for hair loss. The Veteran seeks service connection for hair loss. Specifically, he asserts he has hair loss on his chin since his deployment to the Persian Gulf. The Veteran's service treatment records and post-service treatment records are silent for complaints of, diagnosis of, or treatment for hair loss. VA afforded the Veteran an examination in December 2023. The Veteran reported hair loss on his face and along his jawline which had been treated in the past with steroid injections to help the hair regrow. On examination, there was no evidence of hair loss, and the examiner indicated that any hair loss had resolved. Upon review, the Board concludes that the Veteran does not have a current disability. In addition to a normal VA examination, the medical evidence of record during the pendency of the claim and recent to the filing of the claim is also silent for complaints of, diagnosis of, or treatment for hair loss. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran is advised that he may file a supplemental claim with new and relevant evidence showing a current disability of hair loss during or recent to the current claim or if the condition reoccurs. Accordingly, the evidence is persuasively against the claim of service connection for hair loss. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable, and service connection is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran's claim is denied. 4. Entitlement to service connection for depression. The Veteran seeks service connection for depression. Post-service treatment records are silent for complaints of, diagnosis of, or treatment for depression. VA afforded the Veteran an examination in November 2023. The examiner provided a diagnosis of posttraumatic stress disorder (PTSD) and indicated that a depressed mood was a symptom of the Veteran's PTSD. Upon review, the Board concludes that the Veteran's depression is a symptom associated with his PTSD, rather than a separate and distinct disability. Evidence of a present disability is necessary before service connection may be granted. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability . . . in the absence of a proof of present disability there can be no claim."). The requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal. See Romanowsky v. Shinseki, 26 Vet. Ap. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). While the Veteran believes he has a separate and distinct disability, he is not competent to provide diagnoses in this case. The issue is medically complex and requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. As the evidence indicates that the Veteran's depression is a symptom associated with his PTSD, and not separate and distinct disability, service connection is not warranted. There is not an approximate balance of positive and negative evidence, and the benefit-of-the-doubt doctrine is not applicable. Accordingly, the Veteran's claim is denied. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. 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. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Within that context, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App. 119 (1999). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The standard of proof to be applied in decisions on claims for veteran's benefits is set forth in 38 U.S.C. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD). The Veteran seeks an increased rating for PTSD. The Veteran's PTSD is rated at 50 percent under 38 C.F.R. § 4.130, Schedule of Ratings Mental Disorders, Diagnostic Code (DC) 9411. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. Turning to the evidence of record, VA treatment records are silent for complaints of or treatment for an acquired psychiatric disorder. VA afforded the Veteran an examination in November 2023. The Veteran reported he was cordial with family but that he preferred solitary hobbies such as fishing. He reported he recently stopped working due to stress at his job as a manager. He denied any psychiatric treatment. He reported sleep disturbances, hypervigilance, and difficulty focusing. On examination, the Veteran appeared alert and oriented, well-groomed, and forthcoming. His affect was restricted and congruent with mood. Speech was normal, attention was unimpaired, memory and judgment were intact, and thought processes and content were normal. After reviewing the claims file and examining the Veteran, the examiner found symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships resulting in occupational and social impairment with reduced reliability and productivity Upon review, the Board finds that an initial disability rating in excess of 50 percent is not warranted for PTSD. Here, the Veteran's PTSD is manifest by symptoms associated with a 50 percent rating, such as disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. Although difficulty concentrating is not specifically listed as a symptom in the ratings criteria, the Board finds that it is similar to difficulty understanding complex commands, which is contemplated by a 50 percent rating. The Veteran's PTSD is also manifest by symptoms associated with lesser ratings, such as depressed mood, anxiety, and chronic sleep impairment. Hypervigilance is not specifically listed as a symptom in the ratings criteria, but the Board finds that it is similar to suspiciousness, which is contemplated by a lesser rating. The Board finds that a 70 percent disability rating is not warranted, as the evidence of record persuasively weighs against finding that the severity, frequency, and duration of the Veteran's psychiatric symptoms resulted in the level of impairment required for a 70 percent or higher rating. Here, the evidence does not demonstrate symptoms such as suicidal ideation, obsessional rituals, intermittently illogical, obscure, or irrelevant speech, near-continuous panic or depression, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, an inability to establish and maintain effective relationships, gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Furthermore, the evidence does not demonstrate a level of impairment consistent with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, or total occupational and social impairment. Accordingly, the evidence is persuasively against the claim for an initial disability rating in excess of 50 percent for PTSD. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable, and the Veteran's claim is denied. 6. Entitlement to an initial compensable disability rating for bilateral hearing loss. The Veteran seeks a compensable disability rating for bilateral hearing loss. The Veteran's bilateral hearing loss is rated as noncompensable under 38 C.F.R. § 4.85, Diagnostic Code (DC) 6100. Under DC 6100, a disability for hearing loss is determined by a mechanical application of the Rating Schedule to the numeric designations assigned based upon audiometric test results. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The Rating Schedule provides a table for ratings purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment. Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment in both ears. See 38 C.F.R. § 4.85. The Rating Schedule also recognizes exceptional patterns of hearing impairment. See 38 C.F.R. § 4.86. When the puretone threshold at each of the four specified frequencies (1,000; 2,000; 3,000; and 4,000 Hertz) is 55 decibels or more, Table VI or Table VIa is to be used, whichever results in the higher numeral. 38 C.F.R. § 4.86(a). Additionally, when the puretone threshold is 30 decibels or less at 1,000 Hertz, and 70 decibels or more at 2,000 Hertz, Table VI or Table VIa is to be used, whichever results in the higher numeral. 38 C.F.R. § 4.86(b). Thereafter, that numeral will be elevated to the next higher numeral. Id. In cases where the evaluation of hearing loss is at issue, an examination for VA purposes must be conducted by a state-licensed audiologist and must include a controlled Maryland CNC speech discrimination test and a puretone audiometry test. Examinations will be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). Turning to the evidence of record, a September 2023 VA audiology evaluation was not conducted pursuant the criteria for rating hearing loss but is summarized as normal. VA afforded the Veteran an examination in December 2023. Testing revealed puretone thresholds of 15, 20, 20, and 25 decibels in the right ear, and 25, 30, 30, and 30 decibels in the left ear at the specified frequencies, resulting in average puretone thresholds of 20 decibels in the right ear and 30 decibels in the left ear. A speech discrimination test using the Maryland CNC word list revealed 90 percent in the right ear and 92 percent in the left ear. Applying these results to Table VI in 38 C.F.R. § 4.85 yields a finding of Level II hearing loss in the right ear and Level I hearing loss in the left ear. The audiogram did not reveal an exceptional pattern of hearing loss in either ear. See 38 C.F.R. § 4.86(a). Upon review, the Board finds that an initial compensable disability rating is not warranted. Specifically, the Veteran's bilateral hearing loss was manifest, at most, by Level II hearing loss in the right ear and Level I hearing loss in the left ear. Where hearing loss is at Level II in one ear and Level I in the other, a noncompensable rating is assigned under Table VII. In reaching its conclusions, the Board has also considered the Veteran's complaints regarding the functional impact of his hearing loss on his daily life. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, as noted above, the assignment of disability ratings for hearing impairment is derived from a mechanical formula based on levels of puretone threshold average and speech discrimination. In sum, the Board finds that an initial compensable rating is not warranted for the Veteran's bilateral hearing loss. Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable, and the claim is denied. 7. Entitlement to an initial disability rating in excess of 10 percent for tinnitus. The Veteran seeks an increased rating for tinnitus. The Veteran's tinnitus has been assigned the maximum schedular rating available for tinnitus under Diagnostic Code 6260. Additionally, as the Veteran's disability is explicitly listed in the rating schedule, rating it under an alternate diagnostic code would not be appropriate. See Copeland v. McDonald, 27 Vet. App. 333, 336-37 (2015). Finally, the Veteran has not asserted, nor does the evidence of record show, that his tinnitus presents such an exceptional or unusual disability picture that the application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). Accordingly, the evidence is persuasively against the claim for an initial disability rating in excess of 10 percent for tinnitus. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable, and the Veteran's claim is denied. REASONS FOR REMAND 1. Service connection for acne is remanded. The issue of entitlement to service connection for acne is remanded to correct a duty to assist error that occurred prior to the February 2024 rating decision on appeal. VA obtained an examination and medical opinion in December 2023. However, while the examiner indicated that the Veteran's acne had resolved, it is not clear whether the examiner considered the ameliorative effects of any current medication when finding that the Veteran did not have a current disability. Remand is warranted for a new VA examination and medical opinion. 2. Service connection for photophobia (claimed as a vision disability) is remanded. The issue of entitlement to service connection for photophobia is remanded to correct a duty to assist error that occurred prior to the February 2024 rating decision on appeal. VA obtained an examination in November 2023 and medical opinion in December 2023 in which the examiner opined that the Veteran's photophobia was less likely than not due to exposure to diesel fuel, paint and fumes, and batteries based on medical literature but rather due to traumatic brain injuries and equipment failure explosions. While VA denied service connection for head injuries, the Board notes that the Veteran reported exposure to exploding lead batteries on his August 2023 claim form. Thus, the December 2023 VA medical opinion finding the Veteran's photophobia was not due to exposure to batteries but rather equipment failure explosions is internally inconsistent. VA obtained an addendum opinion in February 2024. However, the examiner's opinion was based on an absence of complaints of or treatment for photophobia during service and is therefore inadequate. Remand is warranted for a new VA medical opinion. 3. Service connection for a left knee disability is remanded. 4. Service connection for a right knee disability is remanded. 5. Service connection for a left ankle disability is remanded. 6. Service connection for a right ankle disability is remanded. 7. Service connection for a left hand disability is remanded. 8. Service connection for a right hand disability is remanded. The issues of entitlement to service connection for bilateral knee, ankle, and hand disabilities are remanded to correct a duty to assist error that occurred prior to the February 2024 rating decision on appeal. VA did not obtain an examination regarding whether these claimed disabilities were incurred in or are otherwise related to service. However, based on the evidence associated with the claims file prior to the February 2024 rating decision, including the Veteran's lay reports of pain and statements regarding the rigors of service, the Board finds that a VA examination and medical opinion is required. 9. Service connection for an unknown skin growth of the left lower abdomen (claimed as a stomach area cyst) is remanded. The issue of entitlement to service connection for an unknown skin growth is remanded to correct a duty to assist error that occurred prior to the February 2024 rating decision on appeal. VA obtained an examination and medical opinion in December 2023. While the examiner indicated that the Veteran had evidence of a current disability, the examiner was unable to opine whether the unknown skin growth was related to in-service toxic exposures because additional testing was needed for a diagnosis. However, VA did not undertake the recommended testing. As such, remand is warranted to obtain a new VA examination and medical opinion. 10. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities is remanded. During a November 2023 VA psychiatric examination, the Veteran reported that he stopped working as a manager in March 2023 due to stress at his job. Thus, the Board finds that entitlement to TDIU has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), as part of the Veteran's PTSD increased rating claim on appeal and that remand is warranted for adjudication by VA in the first instance. 38 C.F.R. § 20.802(a) (the Board has discretion to correct "any other error by the agency of original jurisdiction 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."). The matters are REMANDED for the following actions: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed acne. The examiner must review the claims file. The examiner must determine whether the Veteran has a current disability, to include in the absence of any ameliorative effects of medication used to treat acne. If the examiner finds that the Veteran has a current disability, the examiner is asked to provide a response to the following: Did the Veteran's acne, which existed prior to service, at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) increase in severity during service? If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? Provide a rationale to support the opinion(s). 2. Obtain an opinion from an appropriate clinician regarding the etiology of the Veteran's photophobia. The examiner must review the claims file. An in-person examination is not required unless deemed so by the examiner. The examiner is asked to provide a response to the following: Is the Veteran's photophobia at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service, including exposure to exploding equipment such as batteries? Provide a rationale to support the opinion(s). 3. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed bilateral knee, ankle, and hand disabilities. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that a left and/or right knee, ankle, and/or hand disability (1) began during, or is otherwise related to, active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Provide a rationale to support the opinion(s). In doing so, the examiner is asked to discuss a January 2015 VA treatment record noting complaints of bilateral knee pain after playing kickball while on active duty a few days earlier, a January 2017 periodic health assessment noting knee pain due to running, and the Veteran's lay statements concerning the rigors of service relating to his knees, ankles, and hands. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of his unknown skin growth. The examiner must review the claims file. The examiner should undertake all diagnostic testing required to render an etiological opinion. The examiner is asked to provide a response to the following: Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's skin growth began during or is otherwise related to service, including toxic exposures? Provide a rationale to support the opinion(s). In doing so, the opinion should discuss the total potential exposure through all applicable military deployments and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner is advised that merely stating that the disability is not related to toxic exposures without a supporting rationale is not sufficient. (Continued on next page) ? 5. Adjudicate in the first instance entitlement to a TDIU from February 19, 2023, as part of the increased initial rating claim for PTSD. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Owen, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.