Citation Nr: 18154102
Decision Date: 11/29/18	Archive Date: 11/29/18

DOCKET NO. 17-53 178
DATE:	November 29, 2018
ORDER
Entitlement to service connection for dermatitis is granted.
Entitlement to an increased rating for bilateral sensorineural hearing loss, currently rated as noncompensable, is denied.
REMANDED
Entitlement to service connection for a bilateral shoulder disability is remanded.
Entitlement to service connection for a bilateral elbow disability is remanded.
Entitlement to service connection for a bilateral hand, including wrists, disability remanded.
Entitlement to service connection for a lumbar spine disability is remanded.
Entitlement to service connection for a cervical spine disability is remanded.
Entitlement to service connection for a bilateral hip disability is remanded.
Entitlement to service connection for a bilateral knee disability is remanded.
Entitlement to service connection for a bilateral ankle disability is remanded.
Entitlement to service connection for a bilateral feet disability is remanded.
Entitlement to service connection for hypertensive heart disease is remanded.
Entitlement to service connection for bilateral upper extremity peripheral neuropathy is remanded.
Entitlement to service connection for bilateral lower extremity peripheral neuropathy is remanded.
Entitlement to service connection for an acquired psychiatric disability is remanded.
Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded.
FINDINGS OF FACT
1.  The evidence is at least evenly balanced as to whether the Veteran’s dermatitis is related to active service.
2.  The Veteran demonstrated, at worst, level I hearing acuity in his right ear and level I hearing acuity in his left ear.
CONCLUSIONS OF LAW
1.  Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for dermatitis are met.  38 U.S.C. §§ 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303.
2.  The criteria for a compensable increased rating for bilateral hearing loss have not been met.  38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.159, 4.1-4.7, 4.85, Diagnostic Code (DC) 6100.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from April 1968 to April 1970, including service in the Republic of Vietnam.  
This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).
In May 2018, the Board granted a motion to advance the case on its docket.  38 C.F.R. § 20.900(c).  
I.	Duty to Notify and Assist
The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance.  38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159.  The increased rating for hearing loss is the only claim being denied in this decision.  Accordingly, discussion of VCAA compliance pertains specifically to this issue.
The Veteran was appropriately notified about the information and evidence needed to substantiate the increased rating claim as part of the March 2017 Fully Developed Claim form.  
For the duty to assist, VA satisfied it by obtaining identified and available evidence and affording the Veteran an appropriate VA examination in April 2017.  The audiologist included details about the functional impairment from hearing loss.  Martinak v. Nicholson, 21 Vet. App. 447 (2007).  The Board notes the representative’s objections to the VA audiology examination.  See October 2018 Informal Hearing Presentation.  The representative asserted that the audiological testing took place in artificial conditions and did not accurately reflect the functional impairment.  As noted, the April 2017 VA examination report included the Veteran’s functional impairment description from hearing loss in ordinary conditions. Id.  This is sufficient to comply with the Court’s holding in Martinak, and the contentions that the examination was inadequate in this regard therefore do not warrant remand.  Neither the Veteran nor his representative have not asserted any other deficiency in the examination or a material change in hearing loss severity.  Accordingly, a remand for a new examination is not warranted.
For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of this claim.
II.	Service connection for dermatitis
Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303(a).  Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two.  Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018).  Consistent with this framework, service connection is warranted for a disease first 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).
The Veteran also meets the criteria for a presumption of herbicide agent exposure.  38 C.F.R. § 3.307(a)(6).  Dermatitis is not among the diseases presumptively related to herbicide agent exposure.  38 C.F.R. § 3.309(e).  Nonetheless, service connection may be established on a direct basis to presumed herbicide agent exposure.  See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994).
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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).  
Service treatment records (STRs) from July 1968 showed that the Veteran sought medical attention for lumps on his arms and chin.  The clinician assessed probable sebaceous cyst.  July 1968 STRs showed that the left arm sebaceous cyst was removed.  April 1970 Report of Medical History and physical examination did not note any dermatological disorder. 
In July 2014, Dr. R reported that he had treated the Veteran since 1983 for various medical conditions, including recurrent generalized skin rash and baldness after scalp dermatitis associated with Vietnam service.  He stated that the Veteran developed scalp dermatitis after returning from Vietnam.  His current assessment included findings of crown baldness and recurrent intermittent rash without definitive diagnosis. 
In November 2016, Dr. R provided another summary of care.  He additionally noted generalized pruritus with some macules and papules that resolved with steroid treatment.  His current assessment included crown baldness and recurrent skin rash without a definitive diagnosis.  
In January 2017, Dr. M-Q reported that since active service, the Veteran had dry skin, itching, scales and pruritus affecting the neck, upper back, shoulders and arms.  Dermatology treatment was ineffective.  Dr. M-Q listed a current medical diagnosis of atopic dermatitis.  
VA treatment records from 2011 to 2017 do not include a specific report or complaint for any dermatological problem.  
The Veteran contends that he has had continuous symptoms of dermatitis since service.  Dermatitis symptoms are readily observable, and he is competent to report them.  Although STRs only show treatment for sebaceous cysts, the Veteran’s reports of dermatitis symptoms starting coincident to Vietnam service are not inherently implausible.  Caluza v. Brown, 7 Vet. App. 498, 506 (1995) (VA adjudicators may properly consider internal inconsistency, facial plausibility and consistency with other evidence submitted on behalf of the Veteran in weighing evidence).  His reports are corroborated by Drs. R and M-Q.  Indeed, Dr. R’s reports suggest a longstanding history of dermatitis, with scalp dermatitis specifically being coincident to Vietnam service.  Dr. M-Q related a history of multiple dermatological symptoms affecting the upper body as associated with active service.  The Board finds Drs. R and M-Q’s reports suggesting a nexus to service for dermatitis type symptoms highly probative since both are qualified as physicians.  Id.
The evidence weighing against the claim consists of the VA treatment records.  They show that the Veteran was periodically followed for primary care, but do not include any dermatological complaints or findings.  However, the VA definition of current disability is expansive and includes disability manifestations at any time during the pendency of the claim or even prior thereto.  McClain v. Nicholson, 21 Vet. App. 319 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 303 (2013).  Drs. R and M-Q’s reports support a finding of longstanding dermatitis.  In this particular case, the absence of dermatological in VA treatment records is not sufficient to weigh against the reports of continuous symptoms since service from the Veteran and the private physicians.  See McClain, supra.; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence").
In sum, the evidence is thus at least evenly balanced as to whether the Veteran has had continuous dermatitis symptoms since active military service.   As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for dermatitis is warranted.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.
III.	 Increased rating for bilateral hearing loss
Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity.  38 U.S.C. § 1155; 38 C.F.R. Part 4.  An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment.  38 C.F.R. § 4.10.  When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating.  38 C.F.R. § 4.7.
In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern.  See Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  Staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified.  Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007).
When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant.  38 U.S.C. § 5107(b); 38 C.F.R. § 4.3.
Relevant laws and regulations stipulate that evaluations of defective hearing range from noncompensable to 100 percent based on the organic impairment of hearing acuity.  Hearing impairment is measured by the results of controlled speech discrimination tests together with the average hearing threshold levels (which in turn, are measured by puretone audiometric tests in the frequencies of 1000, 2000, 3000 and 4000 cycles per second (Hertz)).  See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992) (defective hearing is rated on the basis of a mere mechanical application of the rating criteria).  The provisions of 38 C.F.R. § 4.85 establish eleven auditory acuity levels from I to XI.  Tables VI and VII as set forth in section 4.85(h) are used to calculate the rating to be assigned. 
In guidance for cases involving exceptional patterns of hearing impairment, the schedular criteria stipulates that, when the puretone threshold at each of the four specified frequencies (1000, 2000, 3000 and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral.  38 C.F.R. § 4.86(a).  Each ear is evaluated separately.  Additionally, when the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral.  38 C.F.R. § 4.86(b).  The numeral will then be elevated to the next higher Roman numeral.  Id.  Each ear will be evaluated separately. 
In April 2017, the Veteran had a VA audiology examination.  Pure tone thresholds, in decibels, were as follows: 
 	 	HERTZ	 	 
 	1000	2000	3000	4000
RIGHT	15	25 	60 	60 
LEFT	10	20 	65 	65 
 
The average air conduction pure tone threshold decibels for (1000 through 4000 Hz) was 40 for both ears.  Maryland CNC speech discrimination score was 100 percent for both ears.  The examiner reported that both the audiogram and speech discrimination score were appropriate for evaluation.  The audiologist diagnosed bilateral sensorineural hearing loss.  She noted functional impairment from difficulties understanding conversations in noisy situations.  No occupational interference was reported.  
Applying the method for evaluating hearing loss to the results of the Veteran's April 2017 audiological evaluation shows the Veteran did not meet the exceptional pattern of hearing impairment under 38 C.F.R. § 4.86.  The examiner also did not certify that the use of speech discrimination test was not appropriate.  Therefore, the numerical hearing impairment is determined only by Table VI.  The Veteran's hearing acuity is assigned to Level I hearing for his right ear and Level I in his left ear according to Table VI.  Combining Level I hearing for the right ear and Level I hearing for the left ear according to Table VII reveals a noncompensable rating.  38 C.F.R. § 4.85, DC 6100.
In view of the above, a compensable increased rating for bilateral hearing loss is not warranted.  Id.  The Board has considered the Veteran's assertions that the April 2017 audiological evaluation does not accurately represent his hearing loss with daily activities.  The Board in no way discounts the Veteran's reported difficulties and assertions that his hearing loss should be rated higher.  However, the assignment of schedular disability ratings for hearing impairment is derived by a mechanical application of the rating schedule to the numeric designation assigned after audiometry results are obtained.  Thus, the Board has no discretion in this matter and must predicate its determination based on the results of the audiology study of record.  See Lendenmann, supra.  In other words, the Board is bound by law to apply VA's rating schedule based on the audiometry results.  See 38 U.S.C. § 1155; 38 C.F.R. § 4.1.  Under these circumstances, the Board finds that the record presents no basis under the schedular criteria for assignment of a compensable increased rating at any time during the appeal period.  38 C.F.R. § 4.85, DC 6100.
Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three step inquiry for determining whether a Veteran is entitled to an extraschedular rating.  First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate.  Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and it is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms."  Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating.  The recent amendment to 38 C.F.R. § 3.321(b)(1) removes the phrase "upon field station submission," apparently eliminating the concept of extraschedular referral.  See Extra-Schedular Evaluations for Individual Disabilities, 82 Fed. Reg. 57,830, 57,833 (Dec. 8, 2017) ("We agree that the ROs should make these fact-intensive decisions in the first instance, and we have therefore revised the rule by eliminating the phrase 'upon field submission' and the word 'referred'"). 
As to consideration of referral for an extraschedular rating, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those listed in the rating criteria.  Other than difficulty hearing or understanding conversations in noisy situations, the record on appeal contains no evidence of other symptoms attributable to the service-connected bilateral hearing loss, such as, dizziness, vertigo, or ear pain, not contemplated by the rating criteria.   Functional impairment due to hearing loss that is compounded by background or environmental noise is a disability picture that is considered in the current schedular rating criteria; therefore, the Veteran's struggle to comprehend verbal conversations and other noises is contemplated in the regulations and schedular rating criteria.  Doucette v. Shulkin, 28 Vet. App. 366, 371-72 (2017) (difficulty in distinguishing sounds in a crowded environment, locating the source of sounds, understanding conversational speech, hearing the television, and using the telephone are each a manifestation of difficulty hearing or understanding speech, which is contemplated by the schedular rating criteria for hearing loss).  Therefore, referral for extraschedular consideration is not warranted in this case.
For all the foregoing reasons, the increased rating claim for bilateral hearing loss must be denied.  In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, given the mechanical nature of deriving schedular ratings for hearing loss, and that the preponderance of the evidence is against the claim, that doctrine is not applicable.  See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3.
 REASONS FOR REMAND
Entitlement to service connection for disabilities of the bilateral shoulders, bilateral elbows, bilateral hands including wrists, lumbar spine, cervical spine, bilateral hips, bilateral knees, bilateral ankles and bilateral feet are remanded.
In a January 2017, Dr. M-Q. diagnosed the Veteran with degenerative disc disease cervical spine, degenerative joint disease (DJD) of the shoulders, elbows, wrists, hips, knees, ankles and feet, and low back pain, among other diagnoses.  Dr. M-Q. then stated "[t]his is a 68 years old Veteran who presents sensorial, cardiovascular and musculoskeletal diseases with psychiatrics disorders which are more probable than not secundary [sic] to his military service performance."
To date, the Veteran has not been afforded a VA examination to determine the nature and etiology of any of these orthopedic disabilities for which service connection is sought.  The above-cited evidence is sufficient to trigger VA's duty to provide the Veteran examination(s) to determine the nature and etiology for the orthopedic disabilities.  McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006).  The opinion does not, however, have sufficient rationale on which to grant service connection at this time.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning).
Entitlement to service connection for hypertensive heart disease is remanded.
The April 2017 VA cardiology examination showed that the Veteran did not have a heart disorder.  However, the VA examiner did not consider the hypertensive cardiovascular disease and chest pain anterior precordium diagnoses from Dr. R in July 2014 and November 2016 private medical reports.  Additionally, Dr. M-Q diagnosed hypertensive cardiovascular disease and related it to military service.  As noted, the current disability definition for VA compensation purposes is broad and these favorable reports must be considered in determining a current disability.  McClain, supra.; Romanowsky, supra.  An additional medical opinion is needed to fulfill VA's duty to assist in providing a medical opinion that is responsive to the private medical records.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).
The Board notes that the hypertensive heart disease diagnosed by Dr. R is not among the diseases which have been determined to be associated with exposure to herbicides such as Agent Orange.  38 C.F.R. § 3.309(e).  However, a claimant is not precluded from establishing service connection with proof of actual direct causation.  Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994).  Recently, the National Academy of Sciences, Engineering and Medicine (NAS) determined that there is "sufficient" evidence of an association between herbicide exposure and hypertension.  See Veterans and Agent Orange: Update 11 (2018) (November 15, 2018).  Accordingly, in forming the opinion, the examiner must review this literature, and any other medical literature addressing the relationship between hypertensive heart disease and herbicide or Agent Orange exposure.  
Entitlement to service connection for bilateral upper extremity and bilateral lower extremity neuropathy is remanded.  
July 2014 and November 2016 private medical reports from Dr. R. confirmed a diagnosis of peripheral neuropathy and noted longstanding complaints of numbness and tingling in all extremities.  Then, in January 2017, Dr. M-Q reported the Veterans as having neurological disturbances in his upper and lower extremities.  He confirmed a lower extremity peripheral neuropathy diagnosis.  He related “sensorial” disease to the Veteran’s military service.  
To date, the Veteran has not been afforded a VA examination to determine the nature and etiology of any of peripheral neuropathy for which service connection is sought.  The above-cited evidence is sufficient to trigger VA's duty to provide the Veteran examinations to determine the nature and etiology for the upper and lower extremity peripheral neuropathy.  McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006).

Entitlement to service connection for an acquired psychiatric disability is remanded.
The April 2017 VA PTSD examination determined that the Veteran did not have any mental disorder.  However, the VA examiner did not consider the private medical reports.  In July 2014, Dr. R assessed a sleep disorder.  In November 2016, he assessed an anxiety-depressive state diagnosis.  Then, in January 2017, Dr. M-Q diagnosed generalized anxiety disorder, major depression disease, PTSD and memory disorder.  He related the psychiatric disorder to military service.  As noted, the current disability definition for VA compensation purposes is broad and these favorable reports must be considered as showing a current diagnosis.  McClain, supra.; Romanowsky, supra.  An additional medical opinion is needed to fulfill VA's duty to assist in providing a medical opinion that is responsive to the private medical records.  Barr, 21 Vet. App. at 312.
Entitlement to a TDIU is remanded.
Finally, the claim for a TDIU is inextricably intertwined with the claims for service connection, which are being remanded.  See Parker v. Brown, 7 Vet. App. 116   (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue).  As such, the Board will defer adjudication of that claim pending the remand of the other claims remaining on appeal.
The matters are REMANDED for the following action:
1.  Request that the Veteran submit the underlying private medical records from Dr. R.  Furnish an authorization for the release of medical records to the Veteran for him to complete and sign.  Alternatively, advise him that he may directly submit any records in his possession to VA.
2.  After any newly received medical records are associated with the claims folder, schedule the Veteran for a VA examination to determine the nature and etiology of any bilateral shoulder, bilateral elbow, bilateral hand or wrist, lumbar spine, cervical spine, bilateral hip, bilateral knee, bilateral ankle and bilateral foot disability.  The entire electronic claims file must be reviewed by the examiner in conjunction with the examination.
The examiner is requested to opine as to the following:
(a) Is it at least as likely as not (i.e., 50 percent or greater probability) that any bilateral shoulder or elbow disability had its onset in service or is otherwise related to service or in the case of degenerative arthritis, manifested within one year after separation from active service in April 1970?
(b) Is it at least as likely as not (i.e., 50 percent or greater probability) that any bilateral hand or wrist disability had its onset in service or is otherwise related to service or in the case of degenerative arthritis, manifested within one year after separation from active service in April 1970?
(c)  Is it at least as likely as not (i.e., 50 percent or greater probability) that any lumbar spine or cervical spine disability had its onset in service or is otherwise related to service or in the case of degenerative arthritis, manifested within one year after separation from active service in April 1970?
(d)  Is it at least as likely as not (i.e., 50 percent or greater probability) that any bilateral hip or knee disability had its onset in service or is otherwise related to service or in the case of degenerative arthritis, manifested within one year after separation from active service in April 1970?
(e)  Is it at least as likely as not (i.e., 50 percent or greater probability) that any bilateral ankle or bilateral foot disability had its onset in service or is otherwise related to service or in the case of degenerative arthritis, manifested within one year after separation from active service in April 1970?

A complete rationale for all opinions should be provided with specific consideration to the November 2016 and January 2017 private medical records from Drs. R and M-Q respectively.  If the examiner is unable to provide the requested opinion without resort to speculation, the reasons and bases for this conclusion should also be provided.
3.  After any newly received medical records are associated with the claims folder, obtain a cardiology medical opinion from a qualified physician, preferably a cardiologist.  The entire electronic claims file, with specific consideration to the private medical reports from July 2014 and November 2016 by Dr. R and January 2017 by Dr. M-Q.  (A clinical evaluation is only required if deemed necessary by the designated physician).  
The examiner must provide an opinion on whether it is at least as likely as not (a 50 percent probability or greater), that the Veteran's previously diagnosed hypertensive heart disease--as well as any other heart disorder found-(a) had a clinical onset during active service, (b) manifested within one year after separation from active service in April 1970, or (c) is otherwise related to the Veteran's military service, including his presumed in-service exposure to herbicide agents (Agent Orange). 
The examiner is asked to specifically address the latest findings from the National Academies of the Sciences, Engineering and Medicine (NAS) Veterans and Agent Orange: Update 11 (2018) regarding whether there is a relationship between the Veteran's hypertensive heart disease and exposure to herbicide agents (Agent Orange).
A complete rationale for all opinions should be provided and cannot solely rely on an absence of medical studies supporting a nexus.  If the examiner is unable to provide the requested opinion without resort to speculation, the reasons and bases for this conclusion should also be provided.
4.  After any newly received medical records are associated with the claims folder, schedule the Veteran for a VA examination to determine the etiology of any peripheral neuropathy affecting the extremities.  The entire electronic claims file must be reviewed by the examiner in conjunction with the examination.
The examiner is requested to opine as to the following:
(a)  Is it at least as likely as not (i.e., 50 percent or greater probability) that any upper extremity peripheral neuropathy had its onset in service or is otherwise related to service, to include presumed herbicide agent (Agent Orange) exposure?
(b)  Is it at least as likely as not (i.e., 50 percent or greater probability) that any lower extremity peripheral neuropathy had its onset in service or is otherwise related to service, to include presumed herbicide agent (Agent Orange) exposure?
A complete rationale for all opinions should be provided.   If the examiner is unable to provide the requested opinion without resort to speculation, the reasons and bases for this conclusion should also be provided. 
5.  After any newly received medical records are associated with the claims folder, schedule the Veteran for a VA examination to determine the nature and etiology of any psychiatric disorder.  The entire electronic claims file must be reviewed by the examiner in conjunction with the examination with specific consideration to the private medical reports from July 2014 and November 2016 by Dr. R and January 2017 by Dr. M-Q.  
The examiner must provide an opinion on whether it is at least as likely as not (a 50 percent probability or greater), that any of the Veteran's previously diagnosed psychiatric disorders by Drs. R and M-Q, as well as any other psychiatric disorder found, (a) had its onset during active service, (b) is otherwise related to the Veteran's military service, or (c) in the case of PTSD, attributable to an in-service stressor. 
(Continued on the next page)
 

A complete rationale for all opinions should be provided.  If the examiner is unable to provide the requested opinion without resort to speculation, the reasons and bases for this conclusion should also be provided.
 
Jonathan Hager
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	C. D. Simpson, Counsel 

For A Complete Guide To VA Disability Claims and to find out more about your potential VA disability case and how to obtain favorable VA Rating Decision! Visit: VA-Claims.org

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