Citation Nr: 18154103
Decision Date: 11/29/18	Archive Date: 11/29/18

DOCKET NO. 13-22 875
DATE:	November 29, 2018
ORDER
The application to reopen a claim of entitlement to service connection for a right heel disability is granted.
The application to reopen a claim of entitlement to service connection for memory loss is granted.
The application to reopen a claim of entitlement to service connection for the residuals of a groin injury is granted.
The application to reopen a claim of entitlement to service connection for breathing problems is denied.
The claim of entitlement to service connection for chronic fatigue syndrome is denied.
The claim of entitlement to service connection for irritable bowel syndrome is denied.
The claim of entitlement to service connection for diabetes is denied.
The claim of entitlement to service connection for vision loss is denied.
The claim of entitlement to an extension of the Veteran’s temporary total rating under 38 C.F.R. § 4.30 for right elbow contracture release is denied.
The claim of entitlement to an extension of the temporary total rating under 38 C.F.R. § 4.30 for right carpal tunnel release is denied.
The Veteran’s reduced rating for right elbow flexion is restored to 20 percent.
The Veteran’s reduced rating for left upper extremity neuropathy is restored to 20 percent. 
The claim of entitlement to a rating higher than 10 percent prior to October 18, 2011, and higher than 20 percent starting from September 1, 2012, for limited extension due to right elbow arthritis is denied.
A 10 percent rating effective from July 14, 2009, for limited flexion of the right elbow is granted.
The claim of entitlement to a rating higher than 20 percent for limited flexion of the right elbow starting from July 19, 2017, is denied.
A 10 percent rating effective from April 1, 2010, for painful supination of the right elbow is granted.  
A 30 percent initial rating effective from January 27, 2010, and a 40 percent rating effective from March 27, 2018, for right upper extremity neuropathy and carpal tunnel syndrome, is granted.
A 20 percent initial rating for left upper extremity neuropathy is granted.
A 20 percent initial rating for right lower extremity peripheral neuropathy is granted.
The claim of entitlement to an initial rating higher than 10 percent for left lower extremity peripheral neuropathy is denied.  
A 20 percent rating for left lower extremity peripheral neuropathy effective March 27, 2018, is granted.
The claim of entitlement to an initial compensable rating for scar on the right elbow is denied.
The claim of entitlement to an effective date earlier than January 27, 2010, for the grant of service connection for right lower extremity peripheral neuropathy is denied.
The claim of entitlement to an effective date earlier than January 27, 2010, for the grant of service connection for left lower extremity peripheral neuropathy is denied.
An effective date of July 14, 2009, for the award of service connection for limited flexion of the right elbow is granted. 
The claim of entitlement to an effective date earlier than January 27, 2011, for the grant of service connection for an acquired psychiatric disability is denied.
REMANDED
The application to reopen a previously denied claim for service connection for hypertension is remanded.
The claim of entitlement to service connection for a right heel disability is remanded.
The claim of entitlement to service connection for memory loss is remanded.  
The claim of entitlement to service connection for the residuals of a groin injury is remanded.
The claim of entitlement to service connection for a kidney disability is remanded.
The claim of entitlement to service connection for a sleep disability is remanded.
The claim of entitlement to service connection for a right knee disability is remanded.
The claim of entitlement to service connection for a left knee disability is remanded.
The claim of entitlement to service connection for a right shoulder disability is remanded.  
The claim of entitlement to service connection for a left shoulder disability is remanded.
The claim of entitlement to service connection for a right ankle disability is remanded. 
The claim of entitlement to service connection for a left ankle disability is remanded.
The claim of entitlement to service connection for a low back disability is remanded. 
The claim of entitlement to service connection for a neck disability is remanded.
The claim of entitlement to service connection for anemia is remanded.
The claim of entitlement to service connection for headaches is remanded.
The claim of entitlement to service connection for fibromyalgia is remanded.
The claim of entitlement to service connection for a traumatic brain injury is remanded.
The claim of entitlement to service connection for a disability manifesting as chest pain is remanded.
The claim of entitlement to a temporary total rating under 38 C.F.R. § 4.30 for surgery on the knees is remanded.
The claim of entitlement to a total disability based on individual unemployability (TDIU) is remanded.
FINDINGS OF FACT
1. The Veteran’s last claims to service connect a right heel disability and memory loss were denied in an August 2006 rating decision.  His last claim to service connect a groin injury was denied in a February 2007 decision.  He did not appeal those decisions and they are now final.  Since then, new and material evidence has been received that reasonably raises the possibility of substantiating the claims, and they are reopened.
2. His last claim to service connection breathing problems was denied in August 2006.  He did not appeal that decision and it is now final.  The evidence received is cumulative and redundant to what has been previously received, and does not reasonably raise the possibility of substantiating the claim.
3. The Veteran has not been diagnosed with chronic fatigue syndrome or irritable bowel syndrome, or any other functional gastrointestinal disorder, at any time.
4. The preponderance of the evidence weighs against a relationship between diabetes and his active duty service.
5. The Veteran has normal visual acuity.  He does not have a current diagnosis that causes impaired vision.
6. The Veteran was awarded ten months of convalescence, from October 18, 2011, to August 31, 2012, following surgeries to repair right elbow contracture.  The record does not show that he had severe postoperative residuals that required additional convalescence.  He was awarded one month of convalescence, from October 11, 2012, to November 30, 2012, following right carpal tunnel release surgery.  The record does not show that he had severe postoperative residuals that required additional convalescence.   
7. The reduction of his 20 percent rating for limited flexion of the right elbow to 0 percent was improper.  The reduction of his 20 percent rating for left upper extremity neuropathy to 10 percent was improper.
8. The Veteran’s elbow manifests with painful and limited motion that causes some functional loss.  Prior to October 2011, his extension was limited to 35 degrees with pain; after September 2012, his extension was limited to 75 degrees.  Prior to July 2017, his flexion was reduced to 100 degrees with pain; starting from July 2017, his flexion was reduced to 90 degrees.  He has had painful supination since the April 2010 VA examination.
9. Prior to March 27, 2018, the Veteran’s right upper extremity neuropathy and carpal tunnel syndrome manifested as moderate incomplete paralysis of the median nerve; starting from March 27, 2018, it manifested as moderate incomplete paralysis of all radicular groups.  
10. The Veteran’s left upper extremity neuropathy manifests as moderate incomplete paralysis of the median nerve.
11. His right lower extremity peripheral neuropathy manifests as moderate incomplete paralysis of the external popliteal nerve.
12. His left lower extremity peripheral neuropathy initially manifested as mild incomplete paralysis of the external popliteal nerve.  Starting from March 27, 2018, his left lower extremity peripheral neuropathy manifests as moderate incomplete paralysis of the external popliteal nerve.  
13. The Veteran’s scar on the right elbow is linear, stable, and not painful. 
14. The Veteran filed a claim for numbness in his feet that was received January 27, 2010, which has been assigned at the effective date for service connection for right lower extremity peripheral neuropathy and left lower peripheral neuropathy.  No earlier claim, formal or informal, seeking service connection is of record.  
15. The Veteran’s right elbow limited flexion rating was awarded in conjunction with the Veteran’s claim for an increased rating for his right elbow, which was received in July 14, 2009.  His previous claim for an increased rating for the right elbow was adjudicated in a June 2008 rating decision.  His claim was received after the close of the appeal period for the June 2008 rating decision, and there is no other claim, informal or formal, seeking a higher rating for the left elbow that was received after the June 2008 rating decision.  
16. The Veteran filed a claim for service connection for an acquired psychiatric disability that was received June 27, 2011.  There is no earlier claim, formal or informal, for service connection for any acquired psychiatric disability.  The AOJ assigned an effective date of January 27, 2011, in error, which the Board will not disturb.
CONCLUSIONS OF LAW
1. The criteria are met to reopen claims of entitlement to service connection for a right heel disability, for memory loss, and for the residuals of a groin injury.  38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.302, 20.1103.
2. The criteria are not met to reopen a claim of entitlement to service connection for breathing problems.  38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.302, 20.1103.
3. The criteria are not met for service connection for chronic fatigue syndrome or for irritable bowel syndrome.  38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317. 
4. The criteria are not met for service connection for diabetes.  38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309.
5. The criteria are not met for service connection for vision loss.  38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303.  
6. The criteria are not met for an extension of the temporary total ratings assigned for convalescence purposes following surgeries to the right elbow and for right carpal tunnel syndrome.  38 U.S.C. § 1155; 38 C.F.R. § 4.30.
7. The Veteran’s 20 percent rating for limited flexion of the right elbow is restored.  His 20 percent rating for left upper extremity neuropathy is restored.  38 U.S.C. §§ 1155, 5107, 5112; 38 C.F.R. §§ 3.105, 3.344, 4.71a, 4.124a, DCs 5206, 8515.  
8. The criteria are not met for a rating higher than 10 percent prior to October 18, 2011, or higher than 20 percent starting from September 1, 2012, under DC 5207.  The criteria are met for a 10 percent rating effective from July 14, 2009, under DC 5206.  The criteria are not met for a rating higher than 20 percent starting from July 19, 2017, under DC 5206.  The criteria are met for a 10 percent rating effective from April 1, 2010, under DC 5213.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.3, 4.7, 4.45, 4.59, 4.71a, DC 5206, 5207, 5213.
9. The criteria are met for an initial 30 percent rating for right upper extremity neuropathy, effective from January 27, 2010, to March 27, 2018, (notwithstanding his temporary total rating for this disability), and for a 40 percent rating starting from March 27, 2018.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.3, 4.7, 4.123, 4.124, 4.124a, DCs 8513, 8515.
10. The criteria are met for an initial 20 percent rating for left upper extremity neuropathy effective from January 27, 2010.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.3, 4.7, 4.123, 4.124, 4.124a, DCs 8513, 8515.
11. The criteria are met for an initial 20 percent rating for right lower extremity peripheral neuropathy.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.3, 4.7, 4.123, 4.124, 4.124a, DC 8521.
12. The criteria are met for 20 percent rating for left lower extremity peripheral neuropathy starting from March 27, 2018.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.3, 4.7, 4.123, 4.124, 4.124a, DC 8521.
13. The criteria are not met for a compensable rating for scarring on the right elbow.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, DC 7805.
14. The criteria are not met for an effective date earlier than January 27, 2010, for the grant of service connection for right lower extremity peripheral neuropathy and left lower extremity peripheral neuropathy.  38 U.S.C. §§ 5110, 7105; 38 C.F.R. §§ 3.400, 4.124a, DC 8521.
15. The criteria are met for an effective date of July 14, 2009, for the grant of service connection of limited flexion of the right elbow.  38 U.S.C. §§ 5110, 7105; 38 C.F.R. §§ 3.400, 4.71a, DC 5206.
16. The criteria are not met for an effective date earlier than January 27, 2011, for the grant of service connection for an acquired psychiatric disorder.  38 U.S.C. §§ 5110, 7105; 38 C.F.R. §§ 3.400, 4.130, DC 9434-9411.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from November 1990 to June 1991, September 2003 to December 2004, and from September 29, 2005, to October 15, 2005.  
The Board notes the Veteran was previously represented by an attorney, but he revoked that representation and currently is unrepresented.  The Board notes his revoked attorney filed a notice of disagreement (NOD) in September 2017 to the August 2017 rating decision.  Both the Veteran and the attorney were informed that the NOD was not accepted, and the Veteran filed his own timely NOD to that rating decision.  Similarly, in June 2016, his revoked attorney filed a VA Form 9 Appeal to the Board, which was unaccepted; the Veteran filed a timely formal appeal, as well.  The Board also notes the Veteran had requested a hearing before a member of the Board in his September 2017 Form 9, but withdrew that request in a December 2017 statement.  Finally, the Board notes that additional medical evidence has been associated with the file following the RO’s last adjudication of the issues.  In an August 2018 statement, the Veteran waived his right to have the newly received evidence initially reviewed by the RO and asked that the Board proceed with his appeal.     

Service Connection
Service connection is granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).  Service connection may also be granted for a disease diagnosed after discharge, where 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 requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).
1. The application to reopen a claim of entitlement to service connection for a right heel disability is granted.
2. The application to reopen a claim of entitlement to service connection for memory loss is granted.
3. The application to reopen a claim of entitlement to service connection for the residuals of a groin injury is granted.
In general, VA rating decisions or Board decisions that are not timely appealed are final.  See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.1100, 20.1103. A finally disallowed claim may be reopened only when new and material evidence is secured with respect to that claim.  38 C.F.R. § 3.156.  “New” evidence is evidence not previously submitted to agency decisionmakers.  Evidence is “material” if it relates to an unestablished fact necessary to substantiate the claim.  New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim, and must raise a reasonable possibility of substantiating the claim.  38 C.F.R. § 3.156(a).
The Veteran’s claim for service connection for a right heel disability was last denied in an August 2006 rating decision.  The RO found that the Veteran’s right heel plantar fasciitis was not related to his service.  He did not appeal that decision, and it is now final.  Since then, the Veteran’s right foot was examined in July 2009.  The report shows that his service-connected right great toe causes pain throughout his right foot, and that his shoes showed uneven weight-bearing, which supports a relationship between the right heel and the service-connected right great toe.  The Board finds that this evidence is sufficient to reopen, as it raises a reasonable possibility of substantiating the claim.  This issue will be remanded for a VA examination.
His claim for service connection for memory loss was also denied in the August 2006 rating decision, as there was no evidence of a current disability.  He did not appeal that decision, and it has become final.  The Veteran was found, at the April 2018 VA examination, to have impairment of short- and long-term memory.  The Board finds this evidence sufficient to reopen a claim of service connection for memory loss, as it raises a reasonable possibility of substantiating the claim.  This issue is also remanded.
His claim for service connection for a groin injury was last denied in a February 2007 because there was no evidence of residual symptoms from the left groin injury that he had during his service.  Since then, he was found to have a lipoma on the left side of his groin, which has been removed.  He also had an inguinal hernia on the left side of his groin, which has been repaired.  Given the location of the lipoma and hernia, the Board finds this is new and material evidence and raises a reasonable possibility of substantiating the claim.  This issue must be remanded for a medical opinion.
4. The application to reopen a claim of entitlement to service connection for breathing problems is denied.
As discussed above, new and material evidence is required to reopen a previously denied claim.  38 C.F.R. § 3.156(a).  
The Veteran’s claim for service connection for a breathing disability was last denied in an August 2006 rating decision.  He was found to not have a chronic disability manifesting as breathing problems.  He did not appeal the decision, and it is now final.
The Board notes that Section 3.156(a) does not require new and material evidence as to each previously unproven element of a claim, merely that there is a reasonable possibility of an allowance of the claim.  38 C.F.R. 3.156(a); Shade v. Shinseki, 24 Vet. App. 110 (2010).  
The Board finds that none of the evidence obtained and made a part of the record since the August 2006 decision establishes that the Veteran has a chronic disability manifesting as breathing problems.  His VA treatment records only reference breathing in reference to his sleep apnea, which is a separate claim; there are no complaints of difficulty breathing.  (See, for instance, VA treatment dated February 2018, where he denied shortness of breath and wheezing; December 2015, where he received a facemask and filters for his CPAP; May 2012, where he denied shortness of breath and was found to have unlabored breathing).  Indeed, at the May 2010 VA examination, he denied history of asthma, or treatment for bronchitis or pneumonia.  He denied having shortness of breath, chronic cough, sputum production, or hemoptysis.  The only trouble breathing he reported during the examination were the apneic episodes he had while sleeping.  The VA examiner opined that the Veteran’s respiratory issues are limited to sleep apnea, and that he had normal pulmonary function testing that was consistent with his obesity.  Further, he has not provided any statement or argument elaborating on type of breathing problems he has had, aside from his sleep apnea.  The Board finds that this newly received evidence associated with the claims file since the last rating decision is either cumulative or redundant and does not relate to any unproven element of the previously denied claim.
Accordingly, the Board finds that new and material evidence has not been submitted and the claim for service connection for breathing problems is not reopened. Annoni v. Brown, 5 Vet. App. 463 (1993).
5. The claim of entitlement to service connection for chronic fatigue syndrome is denied.  
6. The claim of entitlement to service connection for irritable bowel syndrome is denied.
The Veteran served in Iraq and Kuwait, and therefore he is eligible for consideration of presumptive service connection for certain disabilities occurring in Persian Gulf veterans.  38 C.F.R. § 3.317.  
The Veteran has claimed service connection for chronic fatigue syndrome and for irritable bowel syndrome, which are presumed to be service connected when diagnosed in Persian Gulf veterans under specific circumstances.  38 C.F.R. § 3.317(a).  
The record does not show the Veteran has been diagnosed with either of these disabilities.  The May 2011 VA examiner indicated there was no evidence in the Veteran’s file to suggest he has chronic fatigue syndrome or irritable bowel syndrome.  He has not provided any evidence that he has current diagnoses of these disabilities, or that he has been diagnosed with any other functional gastrointestinal disorder as set forth in 38 C.F.R. § 3.317.  
Accordingly, these claims must be denied, as he does not have current diagnoses.  38 U.S.C. § 1110; Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223 (1992) (generally observing that in the absence of proof of a current disability, there can be no valid claim).
The Veteran has argued that these disabilities are Gulf War undiagnosed illnesses, and that service connection is warranted as a matter of course.  He argues they are defined as undiagnosed illnesses.  This is not a correct interpretation of the regulation.  Service connection is available for the symptoms of undiagnosed illnesses under certain circumstances (and indeed, some of his claims are remanded as possibly related to undiagnosed illness, as discussed below), here he has made specific claims for two diagnosable syndromes, chronic fatigue syndrome (CFS) and irritable bowel syndrome (IBS).  These are medically unexplained chronic multisymptom illnesses.  CFS has specific diagnostic criteria, which the Veteran has not met.  See 38 C.F.R. § 4.88a.  A note to Section 3.317(a)(2)(i)(B)(3) explains that functional gastrointestinal disorders, including IBS, are a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease, and includes a set of diagnostic criteria, which the Veteran has not met.  38 C.F.R. § 3.317.  The record does not show a functional gastrointestinal diagnosis, or persistent symptoms of a functional gastrointestinal disability.  The Board notes he has not reported being diagnosed with these disabilities.  There are complex medical diagnoses that require medical expertise to diagnosis, and the competent evidence weighs against a finding that the Veteran has these two disabilies.
The preponderance of the evidence is against these claims, and they must be denied.  


7. The claim of entitlement to service connection for diabetes is denied.
The Veteran was diagnosed with diabetes in or around May 2015.  He has claimed service connection for diabetes.
He has not been provided a VA examination for an opinion on whether diabetes is related to service, but the Board finds that one is not necessary to decide this claim.  McLendon v. Nicholson, 20 Vet. App. 79 (2006).  An examination is required when there is (1) evidence of a current disability, or persistent or recurrent symptoms of a disability, (2) evidence establishing an “in-service event, injury or disease,” or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case.  Id.  The Board notes the evidentiary requirement for element (3) is low.  Id.  Here, there is no evidence of an in-service injury and no other indication that diabetes may be related to service.  Thus, elements (2) and (3) are lacking. Further, there is nothing that shows his diabetes developed within the year following service, and again, he has not so alleged.  See 38 C.F.R. §§ 3.307(a), 3.309(a).  Indeed, the Veteran has not made any contentions as to why he believes his diabetes is related to his service.  Given the absence of diabetes in his STRs and for nearly ten years following separation, the Board finds there is no indication that it may be related to his service, and that a VA examination is not warranted.  Id.
Accordingly, based on the available evidence, service connection for diabetes is denied.  The record does not show diabetes until May 2015, nearly ten years following his last period of active duty.  There is no allegation of any injury or illness in service that caused his current diabetes.  He has made no indication of how he feels it is related to service.  His treatment providers do not suggest a relationship.  The preponderance of the evidence weighs against this claim.  
 
8. The claim of entitlement to service connection for vision loss is denied.
The Veteran has claimed service connection for loss of vision.
At a November 2017 VA ophthalmology appointment, the Veteran’s visual acuity without correction was found to be 20/20, which is normal.  In February 2018, he denied having experienced any visual changes.  He has not given any specific information on the type of vision loss he is claiming.
Based on the above evidence, the Board finds that service connection is not warranted for vision loss because the record does not show that it is currently diagnosed.  Brammer, supra.  The record does not show any diseases causing loss of vision, and he has not made any specific allegations regarding an acquired eye disability.  Indeed, he has not indicated how any vision loss may be associated with service, except to allege a relationship to diabetes, which is not service connected.  38 C.F.R. § 3.310.  As there is nothing in his STRs, and no indication of a relationship to service, a VA examination is not required.  McLendon, supra.  The preponderance of the evidence weighs against this claim, and it must be denied.
Increased Rating
Disability ratings are assigned in accordance with VA’s Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability.  See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1.  Separate diagnostic codes (DCs) identify the various disabilities.  See generally 38 C.F.R. Part 4.  If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  Reasonable doubt regarding the degree of disability will be resolved in favor of the claimant.  38 C.F.R. § 4.3.  
The Veteran’s claim for an increased rating for his service-connected right elbow was received in July 2009, and has been pending since then.  Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern.  Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  Therefore, the evidence dated from July 2008 through the present will be considered when determining the appropriate rating for his right elbow.  38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). 
The Veteran’s appeals for higher ratings for bilateral upper and lower neuropathies and for right arm scar arise from his disagreement with the initial ratings assigned to these disabilities.  Under these circumstances, 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 a “staged” rating.  Fenderson v. West, 12 Vet. App. 119, 125-126 (1999).  This practice has been extended to all increased-rating claims.  Hart v. Mansfield, 21 Vet. App. 505 (2007).
His claims for extensions of his temporary total ratings, assigned after surgery that requires a convalescence period under 38 C.F.R. § 4.30, will be addressed first.  Then, the Board will address the reductions of his right elbow rating and his left upper extremity neuropathy rating that were recently accomplished in a July 2018 rating decision.  The Board notes he has not appealed these reductions, but they are a part of his appeals for higher ratings for his elbow and neuropathy, and therefore considered an aspect of his increased rating claim.  After addressing these related issues, the Board will then address the Veteran’s increased rating claims.  
9. The claim of entitlement to an extension of his temporary total rating for convalescence purposes for right elbow contracture release is denied.
10. The claim of entitlement to an extension of his temporary total rating for convalescence purposes for right carpal tunnel release is denied.
A total rating (100 percent) for convalescence will be assigned when it is established that entitlement is warranted, effective from the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release. 38 C.F.R. § 4.30.  Entitlement is warranted when surgery necessitates at least one month of convalescence, or when there exist severe postoperative residuals.  38 C.F.R. § 4.30(a).  Extensions of 1, 2, or 3 months beyond the initial 3 months may be made for a total of six months.  38 C.F.R. § 4.30(b)(1).  Extensions of 1 or more months up to 6 months beyond this initial 6-month period may be made upon a determination that there still exist severe postoperative residuals under Section 4.30(a)(2) or immobilization by cast under Section 4.30(a)(3).  38 C.F.R. § 4.30 (b)(2). 
The Veteran has been awarded a temporary total rating under Section 4.30 for two surgeries on his service-connected right elbow, in October 2011 and again in March 2012.  His temporary total rating runs from October 18, 2011, to August 31, 2012, for a total of ten months.  He has appealed for a longer period.
After review of the record, the Board does not find that the Veteran still had severe postoperative residuals, or that his right arm was immobilized in a cast, past the end of August 2012.  His stitches were removed in May 2012, with no signs of infection.  He completed and was discharged from occupational therapy in August 2012, with no suggestion that he had severe postoperative residuals.  The record does not show an incompletely healed wound, therapeutic immobilization of the joint, the necessity for house confinement, or the that regular weight-bearing was prohibited.  Indeed, he was discharged from therapy after having made progress from his baseline.  Accordingly, an extension of the temporary total rating under Section 4.30 is not warranted for the right elbow.
The Veteran was awarded a second period of convalescence following the October 11, 2012, surgery on his service-connected right-sided carpal tunnel syndrome.  It ran for one month, until the end of November 2012.  He has argued that he was in rehabilitation treatment for this surgery until February 2013, and that his period of convalescence should continue through that time.  This is not the standard for whether a temporary total rating should be extended.  Here, the record does not show the Veteran had severe postoperative residuals from his carpal tunnel release.  As above, there is no record of infection or that his surgical wounds were incompletely healed.  His arm was not immobilized and there is no suggestion that weight-bearing was prohibited.  Accordingly, an extension of the temporary total rating under Section 4.30 is not warranted for the Veteran’s right carpal tunnel syndrome.
11. The Veteran’s reduced rating for right elbow flexion is restored to 20 percent.
12. The Veteran’s reduced rating for left upper extremity neuropathy is restored to 20 percent.
The Veteran’s right elbow was rated 20 percent disabling under DC 5206, for limited flexion, effective from July 2017.  In a July 2018 rating decision, his 20 percent rating was reduced to 0 percent, effective from March 2018.  38 C.F.R. § 4.71a, DC 5206; see also 38 C.F.R. § 3.344.
In that same decision, his left upper extremity neuropathy was reduced from 20 percent, effective from April 2016, to 10 percent, effective from March 2018.  38 C.F.R. § 4.124a, DC 8515; see also 38 C.F.R. § 3.344.
The Board finds that the reduction of these ratings was improper.  His 20 percent rating under DC 5206, assigned effective July 2017, is restored.  His 20 percent rating under DC 8515, assigned effective April 2016, is also restored.    
Where a reduction in a rating of a service-connected disability is considered warranted and the lower rating would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons and the Veteran must be notified that he or she has 60 days to present additional evidence. 38 C.F.R. § 3.105(e).  Here, no proposed rating was prepared, despite the fact that these reductions resulted in his total combined rating being reduced from 90 percent to 80 percent.   
Further, certain regulations “impose a clear requirement that VA rating reductions, as with all VA rating decisions, be based upon review of the entire history of the veteran’s disability.”  Brown v. Brown, 5 Vet. App. 413, 420 (1993) (referring to 38 C.F.R. §§ 4.1, 4.2, 4.13).  Ratings that have been in effect for less than five years, such as here, require improvement before an evaluation is reduced.  38 C.F.R. § 3.344(c).  The rating agency must determine whether the improvement actually reflects an improvement in the veteran’s ability to function under the ordinary conditions of life and work.  Brown, 5 Vet. App. at 421.  
Here, in regard to the Veteran’s right elbow limited flexion, upon review of the evidence, the Board finds that the reduction was not proper as the RO did not address whether there was “an actual improvement in the Veteran’s ability to function under the ordinary conditions of life and work.”  Brown, 5 Vet. App. at 421.  Rather, they merely noted that his range of motion had improved.  Specifically, review of the July 2018 rating decision that announced the reduction demonstrates that the RO analyzed the issue of whether a reduction of evaluation was warranted just as it would a claim for an increased rating.  The decision indicated that the results of the April 2018 VA examination showed that a reduction was warranted based on findings that his flexion had improved.  This determination, however, does not address whether the evidence shows an actual improvement in the Veteran’s ability to function.  The preponderance of the evidence does not show this to be the case.  
The July 2017 VA examination, which led to his 20 percent rating for impaired flexion, showed reduced flexion and extension.  He had pain in all ranges of motion, which caused functional loss.  The Veteran complained of chronic pain.  At the April 2018 VA examination, he again showed pain in all ranges of motion, which was determined to cause functional loss, although the examiner did not provide any specific details of the type of functional loss, nor did she record any of his complaints regarding his functionality.  She declined to opine on whether he had additional loss of function during flares or after repetitive use, without explaining why the Veteran’s reports could not be used to determine an estimate.  The record shows he was issued an elbow brace in October 2017, which he continued to wear at the April 2018 VA examination.  In sum, the evidence does not show that his left elbow has actually improved the Veteran’s ability to function under the ordinary conditions of life and work.  
In regard to his left upper extremity neuropathy, the RO similarly did not determine whether there had been an actual improvement in the Veteran’s ability to function.  Rather, they merely noted that his condition had improved, as shown at the March 2018 VA examination, and analyzed the issue in the same manner it would for an increased rating claim.  As above, the preponderance of the evidence does not show an actual improvement in his left arm neuropathy.
The April 2016 VA examination, upon which the 20 percent rating was based, was not significantly different from the March 2018 VA examination.  Both examination reports showed moderate constant pain and mild numbness of the left upper extremity.  The more recent examination showed moderate intermittent pain, which had been previously assessed as severe, and no paresthesia or dysesthesias, which had been previously assessed as mild.   At the April 2016 VA examination, he complained of pain, numbness, and tingling.  He was diagnosed with mild incomplete paralysis of the median nerve.  At the April 2018 VA examination, he complained of chronic pain, and was diagnosed with mild incomplete paralysis of the median nerve, the musculocutaneous nerve, and the circumflex nerve.  The Board notes that neither examination adequately addresses the impact of the Veteran’s neuropathy on his ability to function, which is required to properly reduce a rating.    
Decisions by the RO and by the Board that do not apply the provisions of 38 C.F.R. § 3.344, when applicable, are void ab initio (i.e., at their inception).  Brown, 5 Vet. App. at 413; see also Hayes v. Brown, 9 Vet. App. 67, 73 (1996).  Since the rating decision that accomplished the reduction of the Veteran’s limited elbow flexion from 20 to 0 percent did not properly apply the provisions of 38 C.F.R. § 3.344, the reduction is void.  The appropriate remedy is to restore the 20 percent rating.  See Hayes, 9 Vet. App. at 73.
13. The claim of entitlement to a rating higher than 10 percent prior to October 18, 2011, and higher than 20 percent starting from September 1, 2012, for limited extension of the right elbow is denied.
14. A 10 percent rating effective from July 14, 2009, for limited flexion of the right elbow is granted.  The claim of entitlement to a rating higher than 20 percent starting from July 19, 2017, is denied.
15. A 10 percent rating effective from April 1, 2010, for painful supination of the right elbow is granted.  
Notwithstanding his temporary total rating from October 2011 to August 2012, discussed above, the Veteran’s right elbow is rated under three separate DCs, and is currently staged.  As mentioned above, his claim for an increase was received in July 2009, therefore the relevant time frame for review is from one year prior to receipt of his claim, July 2008.  38 C.F.R. § 3.400(o).  
He argues that he experiences constant pain and has frequent flare ups, including swelling.  He also argues that his functional loss has not been adequately considered.
When evaluating disabilities based on limited motion, it is necessary to consider both the schedular criteria and any functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness.  DeLuca v. Brown, 8 Vet. App. 202 (1995).  Pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability.  38 C.F.R. § 4.45.  Painful, unstable, or malaligned joints, due to a healed injury, are entitled to at least the minimal compensable rating for the joint.  38 C.F.R. § 4.59.  
The Veteran’s right elbow is on his dominant side.  Therefore, the Board will discuss the ratings pertaining to the “major” elbow and forearm.  38 C.F.R. § 4.71a, DCs 5205-5213. 
His limited extension of the right elbow is rated as 10 percent disabling prior to October 18, 2011, and 20 percent disabling starting from September 1, 2012, under DC 5207.  Id.
Under DC 5207, extension limited to 45 degrees warrants a 10 percent rating.  Extension to 60 degrees also warrants a 10 percent rating.  Extension limited to 75 degrees warrants a 20 percent rating.  Extension limited to 90 degrees warrants a 30 percent rating.  Extension limited to 100 degrees warrants a 40 percent rating.  Extension limited to 110 degrees warrants a 50 percent rating.  Id.
After review of the evidence, the Board finds that a rating higher than 10 percent prior to October 18, 2011, is not warranted.  At the July 2009 VA examination, he could not fully extend his forearm and had lost 24 degrees of extension.  At the April 2010 VA examination, his range of motion for extension had increased, and he was only limited to 20 degrees.  He had pain on extension, and occasional swelling that interfered with extension.  In August 2011, VA treatment providers noted he lacked full extension by approximately 25 degrees, and that he was a candidate for surgical options.  At the October 2011 VA examination, his extension was limited to 35 degrees, with pain.  These findings correspond to the criteria for a 10 percent rating.  
The Board acknowledges the Veteran’s complaints of chronic pain, but the evidence does not show that his range of motion has been significantly impacted by these symptoms.  When functional loss is present, it is rated at the same level as functional loss where motion is impeded.  Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991).  Functional loss must be supported by adequate pathology and evidenced by the visible behavior of the claimant.  38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997).  Pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss.  Id.; see also 38 C.F.R. § 4.40.  The evidence does not show or suggest that his elbow pain has caused any further loss in extension than demonstrated at the VA examinations.  The Veteran has not made any allegations regarding his functional loss or whether he has additional loss during flare ups or after repetitive use.  The record does not suggest that his extension was ever reduced to 75 degrees, or the equivalent of that level of disability, prior to October 2011, due to his functional loss or because of flares or repetitive use.  DeLuca v. Brown, 8 Vet. App. 202 (1995). Accordingly, the Board will continue his 10 percent rating for the right elbow limited flexion prior to October 2011.
The Board will also continue the 20 percent rating that is assigned effective from September 2012, after the close of his period of convalescence.  At the June 2012 VA examination, the Veteran’s extension was reduced to 75 degrees, which meets the criteria for a 10 percent rating, and which was assigned by the RO following the close of his convalescent period.  In August 2012, his extension was limited to 30 degrees.  At the April 2016 VA examination, it appears his extension was limited to 65 degrees.  In July 2017, his extension was limited to 40 degrees.  At the April 2018 VA examination, he reportedly had full extension.  These findings meet the criteria to continue his 20 percent rating, but not to increase it.  As above, the Board acknowledges the Veteran’s complaints of pain, but the record does not show that pain or any other type of functional loss has resulted in his extension being limited to 90 degrees or more, which is necessary to meet the criteria for the next higher rating.  DeLuca, supra.
His limited flexion, as discussed above, is rated noncompensably from June 2012, and 20 percent disabling from July 2017 under DC 5206.  The Board notes the July 2018 Rating Decision Code Sheet has a typo and lists this disability under DC 5207; however, the description specifically states limited flexion, which is rated under DC 5206.  
Under DC 5206, flexion limited to 110 degrees warrants a 0 percent rating.  Flexion to 100 degrees warrants a 10 percent rating.  Flexion to 90 degrees warrants a 20 percent rating.  Flexion to 70 degrees warrants a 30 percent rating.  Flexion to 55 degrees warrants a 40 percent rating.  Flexion to 45 degrees warrants a 50 percent rating.  Id.
After review of the evidence, the Board finds that the Veteran is entitled to his separate 10 percent for limited flexion effective from July 14, 2009, the date of his claim for an increased rating for the elbow.  38 C.F.R. § 3.400.  At the July 2009 VA examination, the Veteran limited flexion to 130 degrees.  He had painful flexion at the beginning of the range of motion, around 24 degrees.  He also lost some flexion after repetitions, going down to 122 degrees.  At the April 2010 VA examination, his flexion was reduced to 110 degrees, and he had pain during flexion.  At the October 2011 VA examination, conducted prior to his contracture release, his flexion was reduced to 130 degrees, and he was noted to have painful flexion and weakened movement.  At the June 2012 VA examination, his flexion was reduced to 110 degrees.  These results meet the criteria for a 10 percent rating for painful limited flexion.  38 C.F.R. § 4.59.  Painful flexion was not identified in the record in the year preceding the claim for an increased rating.  The Board notes that awarding him this 10 percent for painful limited motion is not impermissible pyramiding; his rating under DC 5207 compensates him for painful limited extension, and his rating under DC 5206 compensates him for painful limited flexion, which are distinct.  38 C.F.R. § 4.14.
In August 2012 and March 2013, his flexion was reduced to 100 degrees, which meets the criteria for a 10 percent rating.  38 C.F.R. § 4.71a, DC 5206.  
The Board does not find that a higher rating is warranted for limited flexion prior to July 2017.  Prior to the July 2017 VA examination, the Veteran’s flexion was never shown to be limited to 90 degrees.  Even taking into account his functional loss, there is no indication that his flexion was limited to 90 degrees, or in a close approximation of this level of loss, which is required for a 20 percent rating, and he has not so alleged.  DeLuca, supra.
At the July 2017 VA examination, his flexion was reduced to 90 degrees, which meets the criteria for a 20 percent rating under DC 5206.  This is his worst flexion measurement during the appeal period.  The Board does not find that a rating higher than 20 percent is warranted for limited flexion.  Even taking into account his functional loss, there is no indication that his flexion has ever been limited to 70 degrees, or in a close approximation of this level of loss, and he has not so alleged.  DeLuca, supra.  Indeed, at the April 2018 VA examination, his flexion was to 110 degrees, which does not meet the criteria for even a 10 percent rating.  
His impairment of supination and pronation is rated at 10 percent, for painful motion of the forearm, effective from July 2017.
Under DC 5213, limitation of supination to 30 degrees or less warrants a 10 percent rating.  Limitation of pronation beyond the middle of the arc warrants 30 percent; loss of pronation beyond the last quarter of the arc, hand does not approach full pronation warrants a 20 percent rating.  Loss of supination and pronation due to bone fusion warrants a 20, 30, or 40 percent rating depending on the fixation location of the hand.  Id.  
The Veteran had painful reduced supination to 70 degrees, with pain, at the April 2010 VA examination, which had not been demonstrated previously or at the July 2009 VA examination.  He also showed painful supination and pronation at the July 2017 VA examination, and again at the April 2018 VA examination.  This evidence entitles him to his 10 percent under DC 5213 effective from April 1, 2010, the date of the VA examination when it was factually ascertainable that he had reduced and painful supination.  38 C.F.R. § 3.400.  Further, this is not impermissible pyramiding to award this separate rating based on painful motion.  As above, compensation under DC 5213 is for painful supination, which is not addressed by DCs 5206 or 5207.
His elbow is not ankylosed, and there is no impairment of the flail joint, ulna, or radius.  Therefore, DCs 5205, 5209, 5210, 5211, and 5212 are not for application.
16. A 30 percent initial rating effective from January 27, 2010, and a 40 percent rating effective from March 27, 2018, for right upper extremity neuropathy and carpal tunnel syndrome, is granted.
17. A 20 percent initial rating for left upper extremity neuropathy is granted. 
The Veteran has appealed for higher initial ratings for right upper extremity neuropathy and carpal tunnel syndrome, and left upper extremity neuropathy.
His right and left upper extremity disabilities were initially both rated under DC 8515, which pertains to the median nerve.  The criteria for DC 8515 provide for a 10 percent rating for mild incomplete paralysis of the median nerve for both the major and minor extremities.  Moderate incomplete paralysis in the major extremity warrants a 30 percent rating, and 20 percent in the minor.  Severe incomplete paralysis in the major extremity warrants a 50 percent rating, a 40 percent in the minor.  Complete paralysis of the median nerve warrants a 70 percent rating in the major extremity, and 60 percent in the minor extremity.   38 C.F.R. § 4.124a, DC 8515.
The diagnostic code applied to his right upper extremity was changed during the appeal period from DC 8515 to DC 8513, which applies to all radicular groups (including the musculospiral nerve, the median nerve, the ulnar nerve, the musculocutaneous nerve, the circumflex nerve, and the long thoracic nerve).  Under DC 8513, a 20 percent rating is warranted for mild incomplete paralysis of all groups of the major and minor extremities. A 40 percent evaluation is warranted for moderate incomplete paralysis of all radicular groups of the major extremity, while a 30 percent evaluation is warranted for the minor extremity. A 50 percent evaluation is warranted for severe incomplete paralysis of all radicular groups of the major extremity, while a 40 percent evaluation is warranted for the minor extremity. A 70 percent evaluation is warranted for severe incomplete paralysis of the upper, middle lower, and all radicular groups of the major extremity, while a 60 percent evaluation is warranted for the minor extremity. 38 C.F.R.§ 4.124a, DC 8513.
The Board reiterates that the Veteran is right-hand dominant.
A note prior to the rating criteria pertaining to diseases of the peripheral nerves, which contains DCs 8515 and 8513, explains that the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at the most, the moderate degree.  Id. 
A note to the rating criteria indicates that combined nerve injuries should be rated by reference to the major nerve involvement, or if sufficient in extent, consider radicular group ratings.  Id.
Disability ratings with respect to neurological conditions are ordinarily rated in proportion to the impairment of motor, sensory or mental function.  38 C.F.R. § 4.120.  In evaluating peripheral nerve injuries, attention therefore is given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances.  Id.  Special consideration is given to complete or partial loss of use of one or more extremities. 38 C.F.R. § 4.124a.
In regard to the right upper extremity, the Board finds that an initial 30 percent rating is warranted for moderate incomplete paralysis of the median nerve.  In April 2010, an EMG nerve conduction test showed moderate polyneuropathy, and mild median nerve entrapment.  The January 2012 VA examination showed moderate intermittent pain, severe paresthesias and/or dysesthesias and severe numbness.  At the April 2016 VA examination, he had moderate constant pain, severe intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness.  He had normal muscle strength.   Although he was diagnosed with only mild incomplete paralysis at the January 2012 and April 2016 VA examinations, the Board finds that this evidence more closely approximates the criteria for moderate incomplete paralysis than mild.  38 C.F.R. § 4.124a, DC 8515.
The Board does not find a higher rating is warranted for right upper extremity neuropathy and carpal tunnel syndrome until March 27, 2018, the date of the most recent VA examination.  At this examination, he was found to have mild constant pain, mild intermittent pain, and severe numbness.  He had slightly reduced reflexes.  He was diagnosed with mild incomplete paralysis of the median nerve, mild incomplete paralysis of the musculocutaneous nerve, and mild incomplete paralysis of the circumflex nerve.  The Board notes that the AOJ reassigned the diagnostic code to DC 8513 based on these findings showing multiple nerve involvement, which the Board will not disturb.  However, the Board, in resolving all doubt in the Veteran’s favor, finds this evidence to more closely approximate the criteria for moderate incomplete paralysis, given his constant pain, severe numbness, and multiple nerve involvement.  A 40 percent rating is assigned effective from March 27, 2018.  38 C.F.R. §§ 3.400, 4.124a, DC 8513.
The Board does not find that the Veteran’s right upper extremity neuropathy and carpal tunnel syndrome has been severe at any time, under either applicable diagnostic code.  As mentioned, when the involvement is wholly sensory, no more than a moderate degree should be assigned.  Here, the Veteran’s symptoms are almost entirely sensory.  At the January 2012 VA examination, he had slightly reduced strength in his grip and in extending and flexing his elbow, but was able to produce active movement against some resistance.  His muscle strength has since been assessed as normal.  At the April 2016 VA examination, he showed slightly reduced reflexes in the biceps and triceps, which was normal at the March 2018 VA examination.  Although his symptoms have manifested in symptoms effecting his muscle strength and reflexes, they have not been serious or chronic, and are insufficient to show that the Veteran has severe incomplete paralysis.  38 C.F.R. § 4.124a, DCs 8513, 8515.
In regard to the left upper extremity, the Board finds that an initial 20 percent rating for moderate incomplete paralysis of the median nerve is warranted.  As mentioned, the April 2010 EMG nerve conduction test found moderate polyneuropathy.  At the January 2012 VA examination, he had mild intermittent pain, severe paresthesias and/or dysesthesias, and severe numbness.  The Board finds this evidence shows that his left upper extremity neuropathy is moderate.  This award results in a 20 percent rating for this disability for the entire period on appeal.  38 C.F.R. § 4.124a, DC 8515.
The Board does not find that a higher rating is warranted.  His left upper extremity neuropathy has not been severe.  His muscle strength has been normal.  He has not been shown to have reduced reflexes.  His symptoms on the left are wholly sensory, and therefore a higher rating is not warranted.  Id.
 
18. A 20 percent initial rating for right lower extremity peripheral neuropathy is granted.
19. The claim of entitlement to an initial rating higher than 10 percent for left lower extremity peripheral neuropathy is denied.  A 20 percent rating for left lower extremity peripheral neuropathy effective March 27, 2018, is granted.
The Veteran has appealed for higher initial ratings for his right and left lower extremity peripheral neuropathy.
They are each currently rated as 10 percent disabling under DC 8521, which pertains to the external popliteal nerve.  38 C.F.R. § 4.124a.  Under this diagnostic code, mild incomplete paralysis warrants a 10 percent rating.  Moderate incomplete paralysis warrants a 20 percent rating.  Severe incomplete paralysis warrants a 30 percent rating.   Complete paralysis warrants a 40 percent rating.
A note prior to the rating criteria pertaining to diseases of the peripheral nerves, which contains DC 8521, explains that the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at the most, the moderate degree.  Id. 
Disability ratings with respect to neurological conditions are ordinarily rated in proportion to the impairment of motor, sensory or mental function.  38 C.F.R. § 4.120.  In evaluating peripheral nerve injuries, attention therefore is given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances.  Id.  Special consideration is given to complete or partial loss of use of one or more extremities. 38 C.F.R. § 4.124a.
In regard to the right lower extremity, the Board finds that a 20 percent initial rating is warranted, for moderate incomplete paralysis.  The April 2010 EMG nerve conduction test showed moderate polyneuropathy.  At the January 2012 VA examination, the Veteran had moderate intermittent pain, severe paresthesias and/or dysesthesias, and severe numbness.  He also showed reduced senses on the right side.  The April 2016 VA examination showed moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness.  He had reduced senses and reduced reflexes.  The March 2018 VA examination showed severe numbness, and moderate constant pain and intermittent pain.  He had reduced reflexes and decreased senses.  The Board finds this evidence more closely approximates a moderate level of incomplete paralysis.  38 C.F.R. § 4.124a, DC 8521.  
The Board does not find that his right lower extremity peripheral neuropathy has been severe at any time during the appeal period.  His muscle strength has always been normal.  While his reflexes have been decreased, this is the only non-sensory symptom.  His reflexes in the right lower extremity are, at worst, hypoactive, and not absent.  Accordingly, the Board does not find that his right lower extremity peripheral neuropathy has been severe.  Id.
In regard to the left lower extremity, the Board does not find that a higher initial rating is warranted, and that the evidence shows that his left lower extremity peripheral neuropathy is mild.  Although the April 2010 EMG nerve conduction test showed moderate polyneuropathy, at the January 2012 VA examination, his left lower extremity showed normal senses, normal reflexes, and normal muscle strength.  He had mild intermittent pain, severe paresthesias and/or dysesthesias, and moderate numbness.  At the April 2016 VA examination, he had moderate intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness.  He had normal muscle strength and normal reflexes, but some decreased senses.  This evidence shows his peripheral neuropathy was initially mind.  Id.  
A 20 percent rating for the left lower extremity is warranted starting from March 27, 2018, the date of the most recent VA examination.  At that time, he had moderate constant pain, moderate intermittent pain, and mild numbness.  He had reduced reflexes and decreased sense in the foot and toes.  Given the increase in his pain, the Board finds that his left lower extremity peripheral neuropathy increased from mild to moderate, as shown at this examination, and a 20 percent rating is warranted.  Id.
His left lower extremity peripheral neuropathy has not been severe.  Although he has shown some reduced reflexes in the knee and ankle, his reflexes were not absent.  Since this is the only non-sensory involvement, the Board does not find this symptom serious enough to warrant a 30 percent rating for severe.  Id.
20. The claim of entitlement to a compensable rating for scar of the right elbow is denied.
The Veteran is service connected for a scar on the right elbow, which is rated noncompensably under DC 7805, which pertains to other scars and other effects of scars, which directs the rater to rate any symptom under the appropriate diagnostic code.  38 C.F.R. § 4.118.  
Under DC 7805, the disabling effects of scars that are not covered by DCs 7800-7804 are to be rated under an appropriate diagnostic code.  
The record shows the Veteran has two scars on the right elbow, residual from his two elbow contracture release surgeries.  Each is linear, stable, and not painful.  He has complained that the scar occasionally gets bumpy, but that he has never had any treatment for them.  See VA examinations dated in April 2016, July 2017, and April 2018.
Based on this evidence, the Board does not find that a compensable rating is warranted.  The scars are not on the head, face, or neck, and therefore DC 7800 is not available.  The scars are not nonlinear, therefore DCs 7801 and 7802 are not available.  The scars are not painful or unstable, therefore DC 7804 is not available.   38 C.F.R. § 4.118.
The Board considered application of other potentially appropriate diagnostic codes to rate the bumps that occasionally appear on the Veteran’s scar.  A compensable rating would not be available under DC 7806, pertaining to dermatitis or eczema, as less than 5 percent of his entire body and less than 5 percent of his exposed skin is affected.  He does not use any medicinal therapy, topical or otherwise.  Id., DC 7806.  A compensable rating is not warranted under DC 7825, as there is no indication that the bumps that occasionally appear on his scar are severe enough to be treated with an antihistamine or sympathomimetic, or that they frequently occur.  Id., DC 7825.  A compensable rating is not warranted under DC 7828, pertaining to acne, as there is no indication that the bumps that occasionally appear on his scar are deeply inflamed nodules and pus-filled cysts.  Id., DC 7828.
The Veteran has not presented any argument as to his elbow scars.  The preponderance of the evidence is against awarding a compensable rating for the scars.

Effective Date
The effective date for an award of disability compensation based on an original claim for direct service connection is the day following separation from active service or the date entitlement arose if a claim is received within one year after separation from service.  Otherwise, the effective date is the date of receipt of the claim or the date entitlement arose, whichever is later.  38 U.S.C. § 5110; 38 C.F.R. § 3.400.
21. The claim of entitlement to an effective date earlier than January 27, 2010, for the grant of service connection for right lower extremity peripheral neuropathy is denied.
22. The claim of entitlement to an effective date earlier than January 27, 2010, for the grant of service connection for left lower extremity peripheral neuropathy is denied.
The RO has assigned an effective date of January 27, 2010, for the grant of service connection for right and left lower extremity peripheral neuropathy.  He has appealed for an earlier date.
After review of the record, the Board does not find that an earlier effective date is warranted.  His claim for numbness in his feet was received on January 27, 2010.  There are no other communications prior to January 27, 2010, that can be construed as a claim for peripheral neuropathy for the lower extremities.  See 38 C.F.R. § 3.155 (2010).
He argues that the effective date should be earlier, but he does not provide further information on what that date should be.  The record contains no earlier claim, and therefore an earlier effective date is not warranted.  38 C.F.R. § 3.400.
23. An effective date of July 14, 2009, for the award of service connection for limited flexion of the right elbow is granted. 
The Veteran’s limited flexion of the right elbow was granted an effective date of June 21, 2012.  This separate rating was granted in conjunction with the Veteran’s claim for an increased rating for the right elbow.  He seeks an earlier effective date.
Above, in the Increased Rating section of this decision, the Board granted an earlier effective date for limited flexion, back to July 14, 2009, the date of receipt of the Veteran’s claim for an increased rating for the right elbow.
The Veteran’s previous claim for an increased rating for the right elbow was adjudicated in a June 2008 rating decision.  He did not appeal that decision, and it is now final.  There are no communications prior to the July 14, 2009, claim that expressed an interest in an increased rating for the right elbow.
Accordingly, an effective date of July 14, 2009, but no earlier, is warranted for the grant of limited flexion of the right elbow.  38 C.F.R. § 3.400.
24. The claim of entitlement to an effective date earlier than January 27, 2011, for the grant of service connection for an acquired psychiatric disability is denied.
The Veteran’s acquired psychiatric disability was granted an effective date of January 27, 2011, based on the receipt of his claim.  The Board notes that the Veteran’s claim was actually received June 27, 2011, but the Board will not correct this error, as the error is in the Veteran’s benefit.
The Veteran has asserted that he filed a claim for an acquired psychiatric disability in 2005, which the Board was unable to locate.  Indeed, there are no communications regarding mental health symptoms or acquired psychiatric diagnoses earlier than the June 27, 2011, claim.   
Accordingly, as there are no earlier claims, an earlier effective date for the grant of service connection is denied.
REASONS FOR REMAND
1. The application to reopen a previously denied claim of entitlement to service connection for hypertension is remanded.
The Veteran has asserted that his hypertension is caused or aggravated by his sleep apnea.  That claim is being remanded for additional development.  Accordingly, this claim is inextricably intertwined with that claim.  Harris v. Derwinski, 1 Vet. App. 180 (1991).  In other words, the outcome of his sleep apnea claim could have a significant impact on the outcome of this issue, therefore it must also be remanded.  
2. The claim of entitlement to service connection for a right heel disability is remanded.
A medical opinion as to whether the Veteran’s right heel is related to his service-connected right great toe must be obtained.  Further, the Board notes that a May 2005 X-ray (as discussed in the May 2005 VA examination report) showed an osteophyte.  An opinion as to whether this was evidence of arthritis must be obtained.
3. The claim of entitlement to service connection for memory loss is remanded.
The Veteran has been found to have impaired short- and long-term memory, as found on an April 2018 VA examination report for his acquired psychiatric disability.  He has also reported that it is related to his service in Iraq and Kuwait, after exposure to explosions.  Memory loss was not attributed to a traumatic brain injury in the June 2010 VA examination, but an updated examination for that claim will be scheduled, and will address this theory of entitlement.  The Board observes the Veteran has complained of memory loss since December 2004, but it does not appear that he has undergone any formal testing.  An opinion on whether memory loss is a symptom of any illness (diagnosed or undiagnosed) as opposed to a separate disability not previously service-connected must also be obtained. 
4. The claim of entitlement to service connection for the residuals of a groin injury is remanded.
The Veteran injured his groin in June 2004.  In November 2004, it was noted that he had a severe groin pull with bruising in June and July 2004, and that it was not completely healed, and that he still felt it with running and jumping.  He has reported persistent symptoms from that injury.  In May 2017, the Veteran had surgery for an inguinal hernia in the left groin area, and in November 2017, he had a lipoma removed from the left groin area.  No medical opinion has been obtained as to whether these later diagnoses are related to the in-service injury.
5. The claim of entitlement to service connection for a kidney disability is remanded.
An updated VA examination must be conducted.  The Veteran has a current diagnosis of chronic kidney disease and unspecified disorder of the ureter and kidney.  The May 2011 VA examination cited a normal creatinine level of 1.05 to show that his kidney disease is asymptomatic, however, the record shows he has had creatinine levels of over 100 in 2016 and 2017.  Also, he had pretibial edema at the VA examination, which suggests kidney dysfunction.  The Veteran asserts his kidney symptoms are caused by malaria prophylactic (chloroquine) or anthrax vaccine that he took during service.
On remand, an opinion must be obtained as to whether his kidney disease is a specific diagnosis or if his kidney symptoms are caused by an undiagnosed or unknown cause.  The examiner is asked to list all symptoms attributable to Veteran’s kidney disease, and to provide comment on renal dysfunction and voiding dysfunction, if any, as a result of his symptoms.
6. The claim of entitlement to service connection for a sleep disability is remanded.
The Veteran is diagnosed with sleep apnea.  The January 2011 VA examination is not adequate as it does not address all the evidence.  The Veteran did report exposure to burn pits in the Persian Gulf, and he reported on his November 2004 post-deployment health assessment that he was still tired after sleeping.  At the May 2005 VA examination, the Veteran reported that his wife noted since at least November 2004 that the Veteran snored and stopped breathing in his sleep.  He was scheduled for a sleep study, which shows that his symptoms were sufficient to warrant a test.  The examiner cited the Veteran’s weight for the cause of his sleep apnea, but did not consider whether his weight was sufficiently high while still in service, nor the lay evidence about symptoms shown in during active duty.
7. The claim of entitlement to service connection for a right knee disability is remanded.
8. The claim of entitlement to service connection for a left knee disability is remanded.
The Veteran has asserted that his knee disabilities (he has been diagnosed with bilateral meniscus derangement) are related to an altered gait created by his back.  His back is not service connected, but is also being remanded for additional development, therefore these claims are intertwined with that claim.  Harris, supra.  However, the Veteran is service connected for peripheral neuropathy of the bilateral lower extremities, and also for the right big toe; therefore, an opinion on whether these disabilities have caused or aggravated either knee must be obtained.  The current VA examination reports do not address this theory of entitlement.  
9. The claim of entitlement to service connection for a right shoulder disability is remanded.
10. The claim of entitlement to service connection for a left shoulder disability is remanded.
The May 2011 VA examiner’s opinion does not address whether the Veteran’s right and left shoulder disabilities are related to his service-connected right elbow arthritis—which impairs flexion, extension, supination, and pronation—or to his right upper extremity neuropathy and carpal tunnel syndrome, and left upper extremity peripheral neuropathy.  The Veteran has also argued that his bilateral shoulder diagnoses are aggravated by his service-connected acquired psychiatric disability, which has not been addressed. 
11. The claim of entitlement to service connection for a right ankle disability is remanded.
12. The claim of entitlement to service connection for a left ankle disability is remanded.
The Veteran argues that his ankle disabilities are related to an abnormal gait created by his back and his knees.  His back and knees are not service connected, but are also being remanded for additional development, therefore these claims are intertwined with those claims.  Harris, supra.  The May 2011 VA examiner’s opinion does not address whether the Veteran’s right and left ankle disabilities are related to his service-connected right big toe, or to bilateral lower extremity peripheral neuropathy, which should be obtained.  The Veteran argues that his right ankle arthritis is related to arthritis in his right big toe.  The current VA examination reports do not address this theory of entitlement.  
13. The claim of entitlement to service connection for a low back disability is remanded.
The April 2008 VA examiner indicated that there was only one occasion of lumbar strain while in service, but he did not address the fact that the Veteran had symptoms from low back strain for a duration of nearly two months, and he has reported having persistent symptoms since the initial injury.  The Veteran reported that he initially hurt his back while playing football and had to use crutches for two weeks, and that it continued to give him troubles when he was sent to Iraq because his bed was unsupportive.  The examiner is asked to address this evidence.  
14. The claim of entitlement to service connection for a neck disability is remanded.
The Veteran asserts that his neck has been painful since his return from Iraq.  He was diagnosed with degenerative disk disease at the July 2009 VA examination, which was prior to a motor vehicle accident in November 2009 that also injured his neck.  He does not report any injury but asserts that his cervical disability is related to his other service connected disabilities, which has not been specifically addressed by the VA examiner. 
15. The claim of entitlement to service connection for anemia is remanded.
The May 2011 VA examiner did not provide an opinion as to whether anemia is related to service.  The record shows the Veteran has normocytic anemia and B12 deficiency, and that he is prescribed cyanocobalamin for anemia.  It appears to have been diagnosed in April 2006.  A medical opinion as to whether this is a symptom of an undiagnosed illness or otherwise related to service must be obtained.
16. The claim of entitlement to service connection for headaches is remanded.
The Veteran’s headaches have been attributed to his sleep apnea, thus, this claim is inextricably intertwined with that claim.  Harris, supra.  He has further argued that they are related to his acquired psychiatric disability and the medication he takes for that.  The Board notes the June 2012 VA examination does not contain an opinion, and places too much emphasis on a lack of documentation in the records.  Therefore, an updated VA examination should be conducted.
17. The claim of entitlement to service connection for fibromyalgia is remanded.
The Veteran asserts that he has been diagnosed with fibromyalgia.  He shall be given an opportunity to provide records of that diagnosis.  The October 2018 VA examiner indicated that it would be speculation to opine as to whether the Veteran has a fibromyalgia diagnosis but did not explain why.  Accordingly, a VA examination and opinion shall be obtained.
18. The claim of entitlement to service connection for traumatic brain injury (TBI) is remanded.
The June 2010 VA examination opined the Veteran “may” have had mild TBIs following head injuries in 2003, 2004, and October 2009.  It is unclear whether the 2003 potential TBI occurred during active duty, but the October 2009 potential TBI was not during service.  Therefore, a more definite medical opinion is needed.  Further, the examiner indicated that he did not have functional impairment from these TBIs that would render him unemployable, which is not the standard.  On remand, another examination must be conducted for an opinion on whether he has a TBI as a result of his service.
19. The claim of entitlement to service connection for a disability manifesting as chest pain is remanded.
The Veteran reported at the May 2011 VA examination that he has had intermittent nonexertional chest pain since 2004.  His VA treatment records indicate that he was diagnosed with noncardiac chest pain in April 2009.  “Chest pain” is listed in his VA treatment records as a current problem.  On remand, a medical opinion as to whether his chest pain can be attributed to a diagnosis, or otherwise to service, must be obtained.  
20. The claim of entitlement to a temporary total rating under 38 C.F.R. § 4.30 for convalescence following surgery on the knees is remanded.
This claim is inextricably intertwined with his claims for service connection for the right and left knees, and therefore must be remanded because those claims are being remanded.
21.  TDIU.
The issue is TDIU is inextricably intertwined with remanded issues.
The matters are REMANDED for the following action:
1. Ask the Veteran to identify the physician that diagnosed him with fibromyalgia, and ask him to authorize VA to obtain those records.
2. Schedule the Veteran for an appropriate examination of the right foot and heel for a report on whether it is as likely as not that any right heel disability is caused or aggravated by his service or his service-connected right great toe disability.  The examiner is asked to review the record prior to the examination.
He first claimed service connection for the right heel in December 2004, right after separation from service.  He reported developing pain during the preceding year.  His STRs do not show any complaints for the right heel during his service, but that is not dispositive of the claim.  In May 2005, an X-ray revealed an osteophyte on the plantar aspect of the right heel.  The examiner is asked whether this evidence showed he had arthritis within the year following separation.  
A November 2007 X-ray showed spurring of the calcaneus at the plantar aspect. At the July 2009 VA examination, the Veteran had pain on palpation of the arch, with a slightly decreased arch.  Manipulation of the great toe and distal forefoot was painful.  The examiner is asked whether the Veteran’s right great toe has caused or aggravated his right heel disability.  (“Aggravated” means to have caused any increase in severity that is beyond the normal progression of the disability.)
All opinions must be supported with explanation.  
3. Schedule the Veteran for an appropriate examination for a report on whether the Veteran has a disability manifesting as memory loss, or whether memory loss is a symptom of another diagnosis (either a known diagnosis or an undiagnosed illness).
The Veteran attributes his memory loss to the residuals of a TBI.  He has been found to have memory impairment at the April 2018 VA examination for his acquired psychiatric disability.  The examiner is asked to conduct any necessary diagnostic testing.  
If memory loss is due to a separate, known diagnosis, the examiner is asked to opine on whether it is as likely as not (50/50 probability or better) that it is related to his service or a service-connected disability.  The Board notes that he has complained of memory loss since December 2004, the end of a period of active duty service during which he served in Iraq.
If unable to attribute memory loss to a known diagnosis, so state.  
All opinions must be accompanied by explanation.
4. Obtain a medical opinion as to whether the Veteran’s inguinal hernia and/or left groin lipoma are as likely as not (50/50 probability or higher) related to an in-service severe groin strain.  The examiner is asked to review the claims file prior to opining.
In June and July 2004, the Veteran was diagnosed with a groin strain.  In November 2004, at the end of deployment, it was noted the groin strain had been severe, with bruising, that it was not completely healed, and that he still felt it with running and jumping.  He reported the injury to his VA treatment provider in April 2006.  In May 2017, he had surgery to repair an inguinal hernia, and in November 2017, he had a lipoma removed, both from the same area of the groin pull.  
All opinions must be accompanied with explanation.  It is up to the discretion of the examiner as to whether a physical examination is required for this request.  If so, please notify the scheduling authority. 
5. Schedule the Veteran for an appropriate examination for a report on whether the Veteran’s chronic kidney disease and his kidney symptoms are attributed to a specific diagnosis.  If so, please list it.  If his symptoms are not able to be attributed to a specific diagnosis, please state as much.
The Board notes the Veteran’s creatinine was 1.05 at the May 2011 VA examination; however, in renal blood panels taken at VA in 2016 and 2017, he had creatinine levels of 124.10 and 138.30.  He was shown to have pretibial edema at the May 2011 VA examination, which is suggestive of kidney dysfunction.
The examiner is asked to list all renal and voiding dysfunction symptoms, along with any other symptoms.  
The Veteran asserts that his kidney disease is related to malaria prophylactic (chloroquine) and anthrax vaccine taken during service.    To that end, the examiner is asked to conduct a search of the relevant literature prior to rendering an opinion on whether his kidney disability is related.  All opinions must be supported with explanation.  
6. Schedule the Veteran for an appropriate examination for a report on whether it is as likely as not (50/50 probability or better) that sleep apnea is related to his service.  
The Veteran asserts that he developed sleep apnea while serving in Iraq.  His November 2004 post-deployment health assessment notes feeling tired after waking up.  He weighed 288 pounds in May 2003, 275 pounds in August 2003, 276 pounds in October 2003.  At the May 2005 VA examination, he reported that his wife noticed him stop breathing in his sleep and snore since his return from deployment, in November 2004.  In May 2005, he weighed 289 pounds.  Therefore, the examiner is asked to provide an opinion as to whether it is as likely as not (50/50 probability or greater) that the Veteran’s sleep apnea incepted while he was still on active duty, which ended in December 2004.  The Board notes that he was scheduled for a sleep study in May 2005, but did not make the appointment, which suggests that he had clinically objective symptoms at that time.  
All opinions are to be supported with explanatory rationale.  
7. Schedule the Veteran for an appropriate examination for an opinion on whether it is as likely as not (50/50 probability or better) that the Veteran’s right and/or left knee disabilities are caused or aggravated by his service-connected bilateral lower extremity peripheral neuropathy or right big toe.  (“Aggravated” means to cause any increase in severity that is not due to the normal progression of the disease.)
The Veteran has asserted his right and left knee disabilities are related to his altered gait.  Please comment on this theory of entitlement, including whether the Veteran has an altered gait, and if so, list the cause or causes of his altered gait.  He has asserted that he has an altered gait because of his low back disability, which is also being remanded for development.  
The Veteran reports having painful knees since his return from Iraq.  The examiner is asked to elicit from the Veteran a detailed history of the onset of his symptoms, and to review the records prior to opining.
All opinions are to be supported with explanation.
8. Schedule the Veteran for an appropriate examination for an opinion on whether it is as likely as not (50/50 probability or better) that right and/or left shoulder disabilities are caused or aggravated by his right elbow arthritis with painful motion, or his bilateral upper extremity peripheral neuropathy or right carpal tunnel syndrome.  (“Aggravated” means to cause any increase in severity that is beyond the normal progression of the disability.) 
The Veteran has also asserted that his service-connected acquired psychiatric disability aggravates his right and left shoulder disabilities.  
The Veteran reports that he has had pain in his shoulders since returning from Iraq.  The examiner is asked to elicit from the Veteran a detailed history of his symptoms, and to review the records prior to opining. 
All opinions are to be supported with explanation.
9. Schedule the Veteran for an appropriate examination for an opinion on whether it is as likely as not (50/50 probability or better) that right and/or left ankle disabilities are caused or aggravated by his service-connected right big toe, or bilateral lower extremity peripheral neuropathy.  (“Aggravated” means to cause any increase in severity that is beyond the normal progression of the disability.)
He has asserted that his ankle disabilities are caused by altered gait.  Please comment on this theory of entitlement, including whether the Veteran has an altered gait, and if so, list the cause or causes of his altered gait.  He has asserted that he has an altered gait because of his low back and bilateral knee disabilities, which are also being remanded for development.
The Veteran reports that he has had ankle pain since returning from Iraq.  The examiner is asked to elicit from the Veteran a detailed history of his symptoms, and to review the records prior to opining.
All opinions are to be supported with explanation. 
10. Schedule the Veteran for an appropriate examination for a report on whether it is as likely as not (50/50 probability or better) that the Veteran’s low back disability is related to his active duty service.
The Veteran injured his low back in October 2003, and was diagnosed with strain.  He continued to seek treatment for this until the end of November 2003, and was diagnosed with lumbalgia.  He reports that he was on crutches for two weeks, and that he continued to have low back problems thereafter because his cot was unsupportive.  He reports that he has had problems with his back since this injury.  He separated from active duty in December 2004.  He was diagnosed with degenerative disc disease (DDD) at the April 2008 VA examination.  His records do not show any additional low back injury, except for a motor vehicle accident in 2009, which was after a disability had already been diagnosed.  The examiner is asked to provide an opinion as to whether it is as likely as not that DDD or any other disability diagnosed is related to the injury and symptoms in service.
The Veteran has also argued that his low back is aggravated by his acquired psychiatric disability, which should be addressed.
All opinions must be supported with explanation.
11. Schedule the Veteran for an appropriate examination for a report on whether it is as likely as not (50/50 probability or better) that any neck disability, including cervical degenerative disk disorder, is related to his service.  The examiner is asked to review the records prior to the examination.
The Veteran reports having persistent neck pain since returning from Iraq in 2004.  He was diagnosed with degenerative disk disease in July 2009.  His records do not show a neck injury until later in 2009, after DDD was already diagnosed.  The examiner is asked to provide an opinion as to whether it is as likely as not that his DDD incepted while in service, or is related to the pain he described having while in service.  Therefore, it is essential that the examiner elicit from the Veteran a detailed history of his symptoms in and since service.
He has also asserted that his neck disability is related to his other service connected disabilities.  The examiner is asked to provide an opinion as to whether any cervical diagnosis is caused or aggravated by right elbow arthritis, bilateral upper extremity peripheral neuropathy, right-sided carpal tunnel syndrome, bilateral lower extremity peripheral neuropathy, and/or the right big toe.  (“Aggravated” means to cause any increase in severity that is not due to the normal progress of the disability.)
All opinions must be supported with explanation.
12. Obtain a medical opinion as to whether the Veteran’s anemia is attributable to a known diagnosis.  It is up to the discretion of the examiner as to whether a physical examination is also required; if so, please notify the scheduling authority. 
13. Schedule the Veteran for an appropriate examination for an opinion on whether it is as likely as not (50/50 probability or greater) that the Veteran’s headaches are related to his active duty service.  
The Veteran reported having headaches while deployed in Iraq.  He asserts that he has continued to have headaches since then.  The VA examiner is asked to provide an opinion on whether his headaches as likely as not incepted while on active duty?
The examiner is also asked to provide an opinion on whether it is as likely as not that his headaches are caused or aggravated by his acquired psychiatric disability.  (“Aggravated” means to cause any increase in severity that is beyond the normal progression of the disability.)
All opinions are to be accompanied by explanation.
14. Schedule the Veteran for an appropriate examination for a report on whether he meets the diagnostic criteria for fibromyalgia.  If the examiner is unable to provide an opinion without resorting to speculation, an explanation of the evidence that would be required is to be provided.   All opinions are to be supported with explanatory rationale.
15. Schedule the Veteran for an appropriate examination for a report on whether the Veteran has a TBI that is as likely as not (50/50 probability) related to his service.  The examiner is asked to review the claims file prior to the examination and to elicit a detailed history of his injuries in service and symptoms since then.  
The Veteran reports having had a concussion in 2003, but he did not provide more information on whether that was during his period of active duty from September 2003 to December 2004.  He also reports that he had a concussion while in Iraq, which is not shown in the available STRs.  Finally, he was involved in a motor vehicle accident in October 2009, at which time he was again concussed, but which was not during active duty.  The examiner is therefore asked to address whether it is as likely as not that he had a traumatic brain injury during his service, and if so, whether it is as likely as not that he has any residual symptoms from the in-service injury, as opposed to the later injury in 2009.  He has complained of memory loss.
All opinions must be supported with explanation.
16. Schedule an appropriate examination for a report on whether the Veteran’s chest pain is attributable to a known diagnosis.  The examiner is asked to elicit from the Veteran a detailed history of his chest pain, including the frequency of the symptoms and their duration.  
If the chest pain is due to a known diagnosis, the examiner is asked to provide an opinion as to whether it as likely as not (50/50 probability or greater) incepted while he was in service.
 
All opinions must be accompanied with explanation.
    
 
Nathaniel J. Doan
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. Gibson 

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