KNEE IMPAIRMENT OF

Summary

The Veteran served from January 1983 to November 2003. The Veteran appeals the denial of service connection for several conditions, including psoriasis, bilateral ingrown toenails, left heel pain, thoracic spine condition, and melanoma. The Veteran also seeks an increased rating for his service-connected left total knee replacement, hemorrhoids, and left lower extremity radiculopathy. The Board granted service connection for an acquired psychiatric disorder and a left hip condition. The claims for increased ratings for the left knee, hemorrhoids, and left lower extremity radiculopathy were denied, as were the claims for bilateral ingrown toenails and psoriasis. Service connection for left heel pain, thoracic spine condition, melanoma, and bilateral hearing loss were also denied or remanded. The Board found the Veteran's acquired psychiatric disorder to be causally related to service. The left hip condition was granted service connection, found to be secondary to other service-connected conditions based on resolving reasonable doubt in the Veteran's favor. The Board denied service connection for the thoracic spine and left heel conditions, finding them to be manifestations of other service-connected conditions. The case was remanded for a new VA examination for the right hip osteoarthritis due to inadequacies in the previous examinations, specifically regarding range of motion testing and pain assessment in compliance with Correia v. McDonald.

Rationale

Veteran in receipt of maximum evaluation; Criteria for increased rating not met

Full Decision Text

Citation Nr: A26001738
Decision Date: 01/08/26	Archive Date: 01/08/26

DOCKET NO. 250430-539990
DATE: January 8, 2026

ORDER

Entitlement to a rating in excess of 60 percent for the service-connected left total knee replacement is denied. 

Entitlement to a rating in excess of 20 percent for the service-connected hemorrhoids is denied.

Entitlement to a rating in excess of 10 percent for the service-connected left lower extremity radiculopathy is denied.

Entitlement to a compensable rating for the service-connected bilateral ingrown toenails is denied.

Entitlement to a compensable rating for the service-connected psoriasis is denied.

Entitlement to service connection for an acquired psychiatric disorder is granted.

Entitlement to service connection for a left hip condition is granted.

Entitlement to service connection for a thoracic spine condition, to include as secondary to the service-connected low back condition, is denied.

Entitlement to service connection for a left heel condition is denied.

REMANDED

Entitlement to a compensable rating for the service-connected right hip osteoarthritis is remanded.

Entitlement to service connection for bilateral hearing loss is remanded.

Entitlement to service connection for melanoma is remanded.

FINDINGS OF FACT

1. The Veteran is in receipt of the maximum evaluation available under the law for his service-connected left knee post-knee replacement. 

2. The Veteran is in receipt of the highest schedular rating available for his service-connected hemorrhoids. 

3. The Veteran's left lower extremity radiculopathy has been manifested, at worst, by mild incomplete paralysis. Moderate incomplete paralysis has not been shown.

4. The Veteran's bilateral ingrown toenails have been manifested, at worst, by intermittent pain and erythema along the medial border of the nail plate of the bilateral great toenails affecting less than 5 percent of the total body area and none of the exposed area. Burns, larger percentages of the body affected, associated with underlying soft tissue damage, or one or two scars that are unstable or painful have not been shown.

5. The Veteran's psoriasis has been manifested, at worst, by the need for no more than topical therapy required over the past 12-month period and characteristic lesions involving less than 5 percent of the entire body and less than 5 percent of the exposed areas affected. Characteristic lesions involving at least 5 percent but less than 20 percent of the entire body affected or of the exposed area affected have not been shown, nor does the record indicate that the Veteran has been treated with intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. Burns, larger percentages of the body affected, associated with underlying soft tissue damage, or one or two scars that are unstable or painful have not been shown.

6. The Veteran's acquired psychiatric disorder is causally related to his military service.  

7. Resolving reasonable doubt in the Veteran's favor, his left hip condition is secondary to his service-connected left knee, lumbar spine, and right hip conditions. 

8. The persuasive weight of the evidence reflects that the Veteran's thoracic spine pain is a manifestation of his service-connected lumbar spine condition, and the Veteran has not been shown to have an independent thoracic spine condition at any time during the appeal period.

9. The persuasive weight of the evidence reflects that the Veteran's left heel symptoms are manifestations of his service-connected left lower extremity radiculopathy, and the Veteran has not been shown to have an independent left heel condition at any time during the appeal period.

CONCLUSIONS OF LAW

1. The criteria for a rating in excess of 60 percent for the service-connected left total knee replacement have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.71a, Diagnostic Code 5055. 

2. The criteria for a rating in excess of 20 percent for the service-connected hemorrhoids have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.114, Diagnostic Code 7336. 

3. The criteria for a rating in excess of 10 percent for the service-connected left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8520.

4. The criteria for
4.71a, Diagnostic Code 5055. 

2. The criteria for a rating in excess of 20 percent for the service-connected hemorrhoids have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.114, Diagnostic Code 7336. 

3. The criteria for a rating in excess of 10 percent for the service-connected left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8520.

4. The criteria for a compensable rating for the service-connected bilateral ingrown toenails have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7899-7804.

5. The criteria for a compensable rating for the service-connected psoriasis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7816.

6. The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 

7. The criteria for service connection for a left hip condition have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 

8. The criteria for service connection for a thoracic spine condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 

9. The criteria for service connection for a left heel condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from January 1983 to November 2003. 

On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA). This law creates a new framework for Veterans dissatisfied with VA's decision on their claim to seek review. This decision has been written consistent with the new AMA framework.

In a March 2025 rating decision, the Agency of Original Jurisdiction (AOJ) assigned an increased 60 percent rating for the Veteran's service-connected left total knee replacement, effective June 7, 2024, and assigned an increased 20 percent rating for his service-connected hemorrhoids, effective June 7, 2024. The AOJ additionally continued the Veteran's 10 percent rating for his service-connected left lower extremity radiculopathy, continued his noncompensable (0 percent) ratings for his service-connected right hip osteoarthritis, bilateral ingrown toenails, and psoriasis, denied service connection for left heel pain, pain of the thoracic spine, generalized anxiety disorder, and melanoma, and confirmed and continued the previous denials of service connection for bilateral hearing loss and a left hip condition. The Veteran submitted a timely VA Form 10182 (Notice of Disagreement) in April 2025 and, in so doing, requested the Evidence docket. In requesting the Evidence submission lane, he acknowledged that his appeal will be based upon all evidence submitted to VA as of 90 days after the date of that election. 

Evidence was added to the claims file during a period of time when new evidence was not allowed. As such, the Board may not consider this evidence in its decision. 38 C.F.R. § 20.300. The Veteran may file a Supplemental Claim and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

The Board observes that, in the May 2025 rating decision, the AOJ found that new and relevant evidence had been received to reopen the Veteran's previously denied claims and readjud
 claims file during a period of time when new evidence was not allowed. As such, the Board may not consider this evidence in its decision. 38 C.F.R. § 20.300. The Veteran may file a Supplemental Claim and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

The Board observes that, in the May 2025 rating decision, the AOJ found that new and relevant evidence had been received to reopen the Veteran's previously denied claims and readjudicated the Veteran's claims for service connection for bilateral hearing loss and a left hip condition. The Board is bound by these favorable findings. 38 C.F.R. § 3.104(c). Accordingly, a discussion as to whether new and relevant evidence has been received sufficient to readjudicate the claims is not required herein.

In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that the scope of a mental health disability claim includes any mental disorder that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and other information of record. In consideration of this holding, and in light of the evidence of record, the Board has expanded and recharacterized the claim as reflected on the title page. 

Increased Ratings

Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes.?38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment.?38?C.F.R. §?4.10.

The determination of whether an increased rating is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. Schafrath?v.?Derwinski,?1?Vet. App.?589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned.?38?C.F.R. §?4.7.?

While a Veteran's entire history is reviewed when making a disability decision, where service connection has already been established and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern.?Francisco v. Brown,?7?Vet. App.?55 (1994). However, staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different findings.?Fenderson?v. West, 12?Vet. App.?119 (1999);?Hart v. Mansfield, 21?Vet. App.?505 (2007).?

1. Entitlement to a rating in excess of 60 percent for the service-connected left total knee replacement

The Veteran contends that a rating in excess of 60 percent is warranted for his service-connected left total knee replacement. He contends that an 80 percent rating is warranted. April 2025 AMA Form 10182. 

The Veteran's left total knee replacement is rated under Diagnostic Code 5055. Under Diagnostic Code 5055 for knee resurfacing or replacement (prosthesis), a 100 percent rating is warranted for one year following the implantation of the prosthesis. Thereafter, a minimum 30 percent rating is warranted for prosthetic replacement of a knee joint. A 60 percent rating is warranted for prosthetic replacement of a knee joint with chronic residuals consisting of severe painful motion or weakness in the affected extremity. The affected knee may also be evaluated on the basis of intermediate degrees of residual weakness, pain, or limitation of motion by analogy to Diagnostic Codes 5256, 5261, or 5262. 

When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating based on functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination, to include during flare-ups and with repeated use, when those factors are not contemplated in the relevant rating criteria. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40
 or weakness in the affected extremity. The affected knee may also be evaluated on the basis of intermediate degrees of residual weakness, pain, or limitation of motion by analogy to Diagnostic Codes 5256, 5261, or 5262. 

When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating based on functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination, to include during flare-ups and with repeated use, when those factors are not contemplated in the relevant rating criteria. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the Diagnostic Codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996).

Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011).

In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." 

In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination.

A private evaluation is of record dated October 2024. The examiner indicated that the Veteran had suffered from an extension of his condition. The examiner noted that the Veteran has pain of the left knee which is intermittent in varying degrees and intensified with kneeling. The examiner indicated that, on examination, the Veteran was able to perform flexion to 70 degrees with pain and his extension was adequate. Despite providing these range of motion measurements, there is no indication in the examination report that the examiner performed a physical examination of the Veteran, reviewed the claims file, or conducted an interview with the Veteran and it is unclear to the Board how the examiner assessed the severity of the Veteran's condition. The examiner's assessment further failed to take the rating criteria into consideration in assessing the severity of the Veteran's condition. As such, the Board finds the October 2024 private examination to be less probative and inadequate for rating purposes. 

The Veteran was accorded a VA examination in December 2024. The Veteran reported that he still has pain and stiffness in his left knee post-knee replacement surgery. He reported that he has pain three times a week. The Veteran did not report flare-ups. The examiner noted that the Veteran reported functional loss and functional impairment which was described as the Veteran being unable to kneel on his left knee, pain with prolonged sitting, and pain with getting up after prolonged sitting. The Veteran did not report or have a history of instability, recurrent subluxation, or frequent effusion of the knee. The examiner noted that the Veteran's range of motion is abnormal and itself contributes to a functional loss. The Veteran's active range of motion revealed flexion to 65 degrees and extension to 15 degrees. The examiner noted that the Veteran had pain with both flexion and extension but no limitation of motion due to pain. The Veteran's passive range of motion was the same as with active motion and his extension was to 0 degrees. The examiner noted that the Veteran had pain with both flexion and extension and there was no limitation of motion specifically attributable to pain. 

There was objective evidence of localized tenderness or pain on palpitation to the anterior knee of mild severity. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. The Veteran was not examined immediately after repeated use over time. The examiner noted that pain significantly limits functional ability with repeated use over time and was able to describe in range of motion as flexion to 55 degrees and extension to 25 degrees. There was no muscle atrophy, no ligament tear, no recurrent subluxation or persistent instability of the knee, and no recurrent patellar instability. There was no ankylosis of the left knee. The
ion and extension and there was no limitation of motion specifically attributable to pain. 

There was objective evidence of localized tenderness or pain on palpitation to the anterior knee of mild severity. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. The Veteran was not examined immediately after repeated use over time. The examiner noted that pain significantly limits functional ability with repeated use over time and was able to describe in range of motion as flexion to 55 degrees and extension to 25 degrees. There was no muscle atrophy, no ligament tear, no recurrent subluxation or persistent instability of the knee, and no recurrent patellar instability. There was no ankylosis of the left knee. The examiner noted that the Veteran had been diagnosed with a meniscal tear and noted that the Veteran had a total knee replacement in 2022. Residuals of intermediate degrees of residual weakness, pain, or limitation of motion were noted. The examiner indicated that the Veteran's left knee condition impacts his ability to work. The examiner noted that the Veteran lost 0 to 1 week of work time in the last 12 months and that the Veteran cannot kneel on his left knee and has pain with prolonged sitting and with getting up after prolonged sitting. 

The Veteran is in receipt of a 60 percent rating, which is the maximum schedular rating available under Diagnostic Code 5055. There is also no higher rating available under any other provision governing the evaluation of knee disabilities. 

Moreover, the amputation rule provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. See 38 C.F.R. § 4.68. The combined evaluations shall not exceed the 60 percent evaluation set forth under Diagnostic Code 5162, 5163, and 5164 for an amputation of the thigh at the middle or lower thirds; for amputation of the leg with defective stump, thigh amputation recommended; and, amputation not improvable by prosthesis controlled by natural knee action. 38 C.F.R. § 4.68. Thus, the Veteran has been assigned the maximum evaluation that can be granted under the rating schedule for his service-connected left knee post-knee replacement. In other words, as a matter of law, the Veteran cannot be granted a rating in excess of 60 percent for the disability at issue. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994).

Furthermore, the Veteran does not assert that referral for extraschedular consideration is warranted, and the record does not otherwise reasonably raise the matter. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). As such, the Veteran's claim for a rating in excess of 60 percent for the service-connected left knee post-knee replacement is denied.

2. Entitlement to a rating in excess of 20 percent for the service-connected hemorrhoids

The Veteran contends that a rating in excess of 20 percent is warranted for his service-connected hemorrhoids. He contends that a 40 percent rating is warranted. April 2025 AMA Form 10182. 

The Veteran's hemorrhoids are rated under Diagnostic Code 7336. Under Diagnostic Code 7336, a 10 percent rating is warranted for prolapsed internal hemorrhoids with two or less episodes per year of thrombosis, or external hemorrhoids with three or more episodes per year of thrombosis. A maximum 20 percent rating is warranted for internal or external hemorrhoids with persistent bleeding and anemia, or continuously prolapsed internal hemorrhoids with three or more episodes per year of thrombosis. 

A private evaluation is of record dated October 2024. The examiner indicated that the Veteran had suffered from an extension of his condition. The examiner noted that the Veteran suffers from itching, irritation, and bleeding that is treated with dietary restrictions and using a bidet. The examiner noted that the Veteran had followed up with a gastroenterologist and had a colonoscopy. The Veteran reported that he has a constant rectal discharge due to his hemorrhoids. However, there is no indication in the examination report that the examiner reviewed the claims file, performed an examination of the Veteran, or conducted an interview with the Veteran and it is unclear to the Board how the examiner assessed the severity of the Veteran's condition. Additionally, the Board observes that the examiner is a chiropractor who has not been shown to be qualified to assess the severity of hemorrhoids. A chiropractor generally does not have training, education, or experience in medicine or in relation to medical diseases. See American Chiropractic Association website, Origins and history of chiropractic, www.acatoday.org/about/history-of-chiropractic/. The Veteran has not offered any evidence to establish that the October 
 rectal discharge due to his hemorrhoids. However, there is no indication in the examination report that the examiner reviewed the claims file, performed an examination of the Veteran, or conducted an interview with the Veteran and it is unclear to the Board how the examiner assessed the severity of the Veteran's condition. Additionally, the Board observes that the examiner is a chiropractor who has not been shown to be qualified to assess the severity of hemorrhoids. A chiropractor generally does not have training, education, or experience in medicine or in relation to medical diseases. See American Chiropractic Association website, Origins and history of chiropractic, www.acatoday.org/about/history-of-chiropractic/. The Veteran has not offered any evidence to establish that the October 2024 private examiner has such training, education, or experience. The examiner's assessment further failed to take the rating criteria into consideration in assessing the severity of the Veteran's condition. As such, the Board finds the October 2024 private examination to be less probative and inadequate for rating purposes.

A December 2024 VA examination is of record. The examiner provided a diagnosis of external or internal hemorrhoids and noted that the Veteran had a recent colonoscopy that showed internal and external hemorrhoids. The Veteran reported current symptoms of spot bleeding on toilet paper, occasional itching, and pain with bowel movements a few times a week. The examiner noted that the Veteran's treatment plan does not include taking daily medication. The examiner indicated that the Veteran has external hemorrhoids with persistent bleeding and pain with bowel movements. There was no evidence of anorectal or perianal fistula, rectal or anal stricture, functional constipation, impairment of sphincter control, rectal prolapse, or pruritus ani. 

During a July 2025 private treatment visit, the Veteran reported persistent hemorrhoid symptoms. He reported that he has been on a fiber and prebiotic regimen and has normal bowel movements for the past 3 months. The provider indicated that the Veteran has grade III internal hemorrhoids and that he would be scheduled for surgery for excision. No additional diagnoses or conditions were noted during any examination of record, nor were additional diagnoses indicated in the VA and private treatment records. 

The Veteran is in receipt of a 20 percent rating, which is the maximum schedular rating available for hemorrhoids. The Board has considered whether a higher or rating is warranted under a different diagnostic code. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). However, the medical evidence of record does not show that the Veteran has any additional diagnoses or conditions warranting separate or higher ratings under different diagnostic codes. Moreover, the Veteran does not assert that referral for extraschedular consideration is warranted, and the record does not otherwise reasonably raise the matter. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). As such, the Veteran's claim for a rating in excess of 10 percent for the service-connected hemorrhoids is denied. 

3. Entitlement to a rating in excess of 10 percent for the service-connected left lower extremity radiculopathy

The Veteran contends that a higher rating is warranted for his left lower extremity radiculopathy. The Veteran has been assigned a 10 percent rating for left lower extremity radiculopathy. He contends that a 20 percent rating is warranted. April 2025 AMA Form 10182.

The Veteran's left lower extremity radiculopathy has been rated under Diagnostic Code 8520. 38 C.F.R. § 4.124a. This diagnostic code provides the rating criteria for evaluation of the sciatic nerve.

Diagnostic Code 8520 provides a 10 percent rating for mild incomplete paralysis, a 20 percent rating for moderate incomplete paralysis, a 40 percent rating for moderately severe incomplete paralysis, and a 60 percent rating for severe incomplete paralysis with marked muscular atrophy. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. 

The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 
 with marked muscular atrophy. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. 

The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a.

Complete paralysis of the sciatic nerve is indicated where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520.

Words such as "mild," "moderate," "severe," and "pronounced" are not defined in the VA Schedule for Rating Disabilities, so for context and illustrative purposes, the definitions for "moderate" include of average or medium quantity, quality, or extent. WEBSTER'S II NEW COLLEGE DICTIONARY at 704 (1995). Finally, definitions for "severe" include extremely intense. Id. at 1012. It is also noted that the term "moderately severe" indicates impairment that is considered more than "moderate" but not to the extent as to be considered "severe."

Based on the evidence of record, the Board finds that the Veteran's symptomatology is more nearly approximated by the presently assigned 10 percent rating criteria and does not more closely approximate the 20 percent rating criteria as moderate incomplete paralysis has not been shown.

A private evaluation is of record dated October 2024. The examiner indicated that the Veteran had suffered from an extension of his condition. The examiner noted that the Veteran suffers from progressive pain, hypoesthesia, and paresthesia of the left leg as well as constant burning pain of the left heel. The examiner noted that it is intermittent in varying degrees and intensifies with standing, walking, and sitting. The examiner indicated that the Veteran had decreased pinwheel sensation at the L3 and L4 dermatone levels. However, there is no indication in the examination report that the examiner reviewed the claims file, performed an examination of the Veteran, or conducted an interview with the Veteran and it is unclear to the Board how the examiner assessed the severity of the Veteran's condition. Additionally, the Board observes that the examiner is a chiropractor who has not been shown to be qualified to assess the severity of neurological conditions. A chiropractor generally does not have training, education, or experience in medicine or in relation to medical diseases. See American Chiropractic Association website, Origins and history of chiropractic, www.acatoday.org/about/history-of-chiropractic/. The Veteran has not offered any evidence to establish that the October 2024 private examiner has such training, education, or experience. The examiner's assessment further failed to take the rating criteria into consideration in assessing the severity of the Veteran's condition. As such, the Board finds the October 2024 private examination to be less probative and inadequate for rating purposes. 

A VA back conditions examination was obtained in December 2024. The examiner indicated that the Veteran had no radicular pain or signs or symptoms due to radiculopathy. In the remarks section of the examination report, the examiner clarified that, while the Veteran does have radiculopathy, it would not be addressed in this examination report. 

A VA peripheral nerves examination is of record dated December 2024. The examiner provided a diagnosis of left lower extremity radiculopathy. The Veteran reported that his condition goes up and down and that he receives injections that give him 8 to 10 weeks of relief followed by 4 to 6 weeks of pain before the next injection. Radicular symptoms of moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness were noted. The Veteran's muscle strength was normal, he had no muscle atrophy, and his reflexes and sensory examination were normal. The Veteran's gait was noted to be normal. The examiner indicated that there was mild incomplete paralysis of the sciatic nerve on the left side. and mild incomplete paralysis of the posterior tibial nerve. Moderate, moderately severe, or severe incomplete paralysis or complete paralysis was not indicated. 

The Board finds that the criteria for a rating in excess of 10 percent are not met for the Veteran's left lower extremity radiculopathy. The disability was regularly found to be of mild
 symptoms of moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness were noted. The Veteran's muscle strength was normal, he had no muscle atrophy, and his reflexes and sensory examination were normal. The Veteran's gait was noted to be normal. The examiner indicated that there was mild incomplete paralysis of the sciatic nerve on the left side. and mild incomplete paralysis of the posterior tibial nerve. Moderate, moderately severe, or severe incomplete paralysis or complete paralysis was not indicated. 

The Board finds that the criteria for a rating in excess of 10 percent are not met for the Veteran's left lower extremity radiculopathy. The disability was regularly found to be of mild severity on examination. Moderate, moderately severe, or severe incomplete paralysis has not been shown. Accordingly, the Veteran's left lower extremity radiculopathy has not approximated the criteria for a rating in excess of 10 percent. 

The Board finds that assigning separate ratings under Diagnostic Codes 8521, 8522, 8523, 8524, 8525, or 8526 for the external popliteal, musculocutaneous, anterior tibial, internal popliteal, and posterior tibial nerves, respectively, is not warranted. Such would constitute impermissible pyramiding as impairment of these nerves all contributed to the same and overlapping functional impairment of the lower extremities consisting of pain, paresthesias, numbness, and gait changes. VA regulations prohibit evaluation of the same disability or the same or overlapping symptomatology under different diagnostic codes (which is called "pyramiding"). 38 C.F.R. § 4.14. 

The Board is sympathetic to the Veteran's belief that a higher rating is warranted for his left lower extremity radiculopathy. However, the evidence of record, when compared to the rating criteria, does not warrant a higher rating at any time during the appeal period. Accordingly, the Board finds that the persuasive weight of the evidence is against this claim, and the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

4. Entitlement to a compensable rating for the service-connected bilateral ingrown toenails

The Veteran contends that a higher rating is warranted for his service-connected bilateral ingrown toenails. The Veteran has been assigned a noncompensable (0 percent) rating. He contends that a 10 percent rating is warranted. April 2025 AMA Form 10182.

The Veteran's bilateral ingrown toenails have been rated under Diagnostic Code 7899-7804. 38 C.F.R. § 4.118. The use of a hyphenated code here indicates the rating is based on analogy to a listed disability in the rating schedule. 38 C.F.R. § 4.27. In this instance, Diagnostic Code (DC) 7899 signifies the underlying condition is unlisted skin related disability, while DC 7804 indicates the analogous condition is scar(s), unstable or painful. Thus, the applicable diagnostic criteria are prescribed under DC 7804.

Diagnostic Code 7804 applies to unstable or painful scars. A 10 percent disability rating is warranted if there are one or two scars that are unstable or painful. A 20 percent disability rating is warranted if there are three or four scars that are unstable or painful. A 30 percent disability rating is warranted if there are five or more scars that are unstable or painful. 

DC 7800 applies to burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. A 10 percent disability rating is warranted with one characteristic of disfigurement, which are: scar 5 or more inches (13 or more centimeters (cm.)) in length; scar at least one-quarter inch (0.6 cm.) wife at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo-or hyper-pigmented in an area exceeding six square inches (39 square (sq.) cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); or skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). 

Diagnostic Code 7801 applies to burn scar(s) or other scar(s) due to other causes, not of the head, face or neck, that are associated with underlying soft tissue damage. A 10 percent disability rating is warranted if the area or areas covered is at least 6 square inches
-pigmented in an area exceeding six square inches (39 square (sq.) cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); or skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). 

Diagnostic Code 7801 applies to burn scar(s) or other scar(s) due to other causes, not of the head, face or neck, that are associated with underlying soft tissue damage. A 10 percent disability rating is warranted if the area or areas covered is at least 6 square inches (39 sq. cm.), but less than 12 square inches (77 sq. cm.). A 20 percent disability rating is warranted if the area or areas covered is at least 12 square inches (77 sq. cm.), but less than 72 square inches (465 sq. cm.). A 30 percent disability rating is warranted if the area or areas covered is at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.). A 40 percent disability rating is warranted if the area or areas covered is at least 144 square inches (929 sq. cm.) or greater.  

Diagnostic Code 7802 applies to burns scar(s) or scar(s) due to other causes, not of the head, face or neck, that are not associated with underlying soft tissue damage.  A 10 percent disability rating is warranted if the area or areas covered is at least 144 square inches (929 sq. cm) or greater.

Diagnostic Code 7805 applies to other scars and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7804, which notes that any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under an appropriate Diagnostic Code.

A private evaluation is of record dated October 2024. The examiner indicated that the Veteran had suffered from an extension of his condition. The examiner noted that the Veteran continues to have intermittent pain of the bilateral great toenails with wearing closed toed shoes. The examiner noted that the Veteran self-treats his toenails. However, there is no indication in the examination report that the examiner reviewed the claims file, performed an examination of the Veteran, or conducted an interview with the Veteran and it is unclear to the Board how the examiner assessed the severity of the Veteran's condition. Additionally, the Board observes that the examiner is a chiropractor who has not been shown to be qualified to assess the severity of dermatological conditions. A chiropractor generally does not have training, education, or experience in medicine or in relation to medical diseases. See American Chiropractic Association website, Origins and history of chiropractic, www.acatoday.org/about/history-of-chiropractic/. The Veteran has not offered any evidence to establish that the October 2024 private examiner has such training, education, or experience. The examiner's assessment further failed to take the rating criteria into consideration in assessing the severity of the Veteran's condition. As such, the Board finds the October 2024 private examination to be less probative and inadequate for rating purposes. 

The Veteran was accorded a VA examination in December 2024. The examiner, in relevant part, provided a diagnosis of bilateral ingrown toenails. The Veteran reports flare-ups several times a year. The Veteran reported that he was using two medications as needed but that he was unable to remember their names. The examiner noted that the Veteran has not had any treatments or procedures other than systemic or topical medications in the past 12 months. Upon physical examination, the Veteran's bilateral ingrown toenails were noted to affect less than 5 percent of the total body area and none of the exposed area. The condition was described as erythema along the medial border of the nail plate of the bilateral great toenails. 

During a June 2025 private treatment visit, the Veteran was observed to have ingrowing toenails of the bilateral hallux medial borders. The provider indicated that the toenails were not infected or significantly painful on the day of the visit. The bilateral hallux toenail medial borders were slightly incurvated and cut short. There were no clinical signs of infection but the provider did note very mild tenderness to palpitation of the bilateral hallux medial borders. 

After reviewing the relevant evidence of record, the Board finds that a compensable rating is not warranted for the Veteran's service-connected bilateral ingrown toenails. The Veteran's bilateral ingrown toenails have been manifested, at worst, by intermittent pain and erythema along the medial border of the nail plate of the bilateral great toenails affecting less than 5 percent of the total body area and none of
ux medial borders. The provider indicated that the toenails were not infected or significantly painful on the day of the visit. The bilateral hallux toenail medial borders were slightly incurvated and cut short. There were no clinical signs of infection but the provider did note very mild tenderness to palpitation of the bilateral hallux medial borders. 

After reviewing the relevant evidence of record, the Board finds that a compensable rating is not warranted for the Veteran's service-connected bilateral ingrown toenails. The Veteran's bilateral ingrown toenails have been manifested, at worst, by intermittent pain and erythema along the medial border of the nail plate of the bilateral great toenails affecting less than 5 percent of the total body area and none of the exposed area. No scars have been shown. 

Aside from the above, there is no other medical evidence of record relevant to this claim.

The Board acknowledges that the Veteran believes that his service-connected bilateral ingrown toenails condition is more severe than the assigned disability rating reflects. However, other than his general contention that he is entitled to a compensable rating for this condition, he has not submitted any lay statements relevant to this claim. 

The Board has considered whether the application of any other Diagnostic Codes would provide for a higher disability evaluation. However, the evidence does not reflect that a higher rating is warranted under any other Diagnostic Code, as the Veteran's bilateral ingrown toenails have not been manifested by burns, larger percentages of the body affected, associated with underlying soft tissue damage, or with one or two scars that are unstable or painful. As such, the Veteran's bilateral ingrown toenails have not more nearly approximated the criteria for a 10 percent rating. 

Based on the foregoing, the Board finds that the persuasive weight of the evidence is against finding that a compensable rating is warranted for the service-connected bilateral ingrown toenails. As such, the Veteran's claim is denied. 

5. Entitlement to a compensable rating for the service-connected psoriasis

The Veteran contends that a higher rating is warranted for his service-connected psoriasis. The Veteran has been assigned a noncompensable (0 percent) rating. He contends that a 20 percent rating is warranted. April 2025 AMA Form 10182.

The Veteran's service-connected psoriasis is evaluated under 38 C.F.R. § 4.118, Diagnostic Code 7816. 

Disabilities rated under DC 7816 are to be evaluated under the General Rating Formula for the Skin. A noncompensable rating is assigned when no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned when the record demonstrates at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is assigned when the record demonstrates at least one of the following: characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or Systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly over the past 12-month period. A 60 percent rating is assigned when the record demonstrates at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. See 38 C.F.R. § 4.118, DC 7816.

A disability under DC 7816 may also be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), depending on the predominant disability. See 38 C.F.R. § 4.118.

Under the General Rating Formula for the Skin, "
 or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. See 38 C.F.R. § 4.118, DC 7816.

A disability under DC 7816 may also be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), depending on the predominant disability. See 38 C.F.R. § 4.118.

Under the General Rating Formula for the Skin, "systemic therapy" is defined as "treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin," and "topical therapy" is defined as "treatment that is administered through the skin." See 38 C.F.R. § 4.118(a).

A private evaluation is of record dated October 2024. The examiner indicated that the Veteran had suffered from an extension of his condition. The examiner noted that the Veteran has followed up with a dermatologist and was diagnosed with sebaceous dermatitis. The examiner remarked that the Veteran's condition appears with constant redness and exfoliation on the face and that he has intermittent burning. The examiner noted that the Veteran continues to follow up with Walter Reed National Military Medical Center and was recommended medicated ointment. However, there is no indication in the examination report that the examiner reviewed the claims file, performed an examination of the Veteran, or conducted an interview with the Veteran and it is unclear to the Board how the examiner assessed the severity of the Veteran's condition. Additionally, the Board observes that the examiner is a chiropractor who has not been shown to be qualified to assess the severity of dermatological conditions. A chiropractor generally does not have training, education, or experience in medicine or in relation to medical diseases. See American Chiropractic Association website, Origins and history of chiropractic, www.acatoday.org/about/history-of-chiropractic/. The Veteran has not offered any evidence to establish that the October 2024 private examiner has such training, education, or experience. The examiner's assessment further failed to take the rating criteria into consideration in assessing the severity of the Veteran's condition. As such, the Board finds the October 2024 private examination to be less probative and inadequate for rating purposes. 

The Veteran was accorded a VA examination in December 2024. The examiner, in relevant part, provided a diagnosis of psoriasis to also include sebaceous dermatitis. The examiner noted that the Veteran has psoriasis on the ears, scalp, and face. The Veteran reported that he is currently using two different creams as needed but he was unsure of the names as he has tried so many medications and cannot remember the current regimen. The examiner noted that the Veteran has treated his psoriasis with topical medication for 6 weeks or more but not constantly. The examiner noted that the Veteran has not had any treatments or procedures other than systemic or topical medications in the past 12 months. Upon physical examination, the Veteran's psoriasis was noted to affect less than 5 percent of the total body area and less than 5 percent of the exposed area. The appearance of the condition was described scaly plaques on an erythematous base consistent with psoriasis above the left eyebrow and center of forehead near the hairline. 

After reviewing the relevant evidence of record, the Board finds that a compensable rating is not warranted for the Veteran's service-connected psoriasis. The Veteran's psoriasis has been manifested, at worst, by the need for no more than topical therapy required over the past 12-month period and characteristic lesions involving less than 5 percent of the entire body and less than 5 percent of the exposed areas affected. Characteristic lesions involving at least 5 percent but less than 20 percent of the entire body affected or of the exposed area affected have not been shown, nor does the record indicate that the Veteran has been treated with intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. 

Aside from the above, there is no other medical evidence of record relevant to this claim.

The Board acknowledges that the Veteran believes that his service-connected psoriasis is more severe than the assigned disability rating reflects. However, other than his general contention that he is entitled to a compensable rating for this condition, he has not submitted any lay statements relevant to this claim. 

The Board has considered whether the application of any other
 the Veteran has been treated with intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. 

Aside from the above, there is no other medical evidence of record relevant to this claim.

The Board acknowledges that the Veteran believes that his service-connected psoriasis is more severe than the assigned disability rating reflects. However, other than his general contention that he is entitled to a compensable rating for this condition, he has not submitted any lay statements relevant to this claim. 

The Board has considered whether the application of any other Diagnostic Codes would provide for a higher disability evaluation. However, the evidence does not reflect that a higher rating is warranted under any other Diagnostic Code, as the Veteran's psoriasis has not been manifested by burns, larger percentages of the body affected, associated with underlying soft tissue damage, or with one or two scars that are unstable or painful. As such, the Veteran's psoriasis has not more nearly approximated the criteria for a 10 percent rating. 

Based on the foregoing, the Board finds that the persuasive weight of the evidence is against finding that a compensable rating is warranted for the service-connected psoriasis. As such, the Veteran's claim is denied.

Service Connection

Service connection is granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§?1110, 1131; 38?C.F.R. §?3.303. Service connection requires competent evidence of: (1) the existence of a present disability; (2) inservice 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). Under?38?C.F.R. §?3.303(b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as "chronic" in?38?C.F.R. § 3.309(a).?Walker v. Shinseki,?718 F.3d 1331 (Fed. Cir. 2013).

Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury; or any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310(a)-(b). Secondary service connection requires evidence of (1) a current disability, (2) a service-connected disability, and (3) a nexus, or link, between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998).

The existence of a current disability is the cornerstone of a claim for VA disability compensation. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The presence of a chronic disability at any time during the claim process can justify a grant of service connection, even if the disability has since resolved or where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007).

In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the weight of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant.

To deny a claim on its merits, the weight of the evidence must persuasively stand against a finding that the evidence is in "approximate balance" or "nearly equal" to the evidence that supports the claim. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

6. Entitlement to service connection for an acquired psychiatric disorder

The Veteran contends that he has an acquired psychiatric disorder related to his service. Available medical evidence includes diagnoses of depression and generalized anxiety disorder. September 2003 VA Examination and October 2024 Private Disability
 balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant.

To deny a claim on its merits, the weight of the evidence must persuasively stand against a finding that the evidence is in "approximate balance" or "nearly equal" to the evidence that supports the claim. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

6. Entitlement to service connection for an acquired psychiatric disorder

The Veteran contends that he has an acquired psychiatric disorder related to his service. Available medical evidence includes diagnoses of depression and generalized anxiety disorder. September 2003 VA Examination and October 2024 Private Disability Benefits Questionnaire (DBQ). These diagnoses satisfy the first element of service connection. 

The Veteran's service treatment records (STRs) do not include any complaints of, or treatment for, a psychiatric disorder. The Veteran contends that his acquired psychiatric disorder is related to being responsible for launching up to 50 nuclear missiles while serving as an ICBM (intercontinental ballistic missile) combat crewmember at Malmstrom Air Force Base. He additionally reports that, during the September 11 terrorist attacks, he was on the top floor of a building near the Pentagon when the plane that struck the Pentagon flew less than 100 feet overhead. The Veteran contends that in response to these incidents, he increased his alcohol consumption, faced significant martial issues, and experienced episodes of depression, panic attacks, or anxiety. He contends that he spoke with a psychiatrist and to a chaplain or clergy member during his retirement physical, and the Board observes that the Veteran reported marital issues and psychiatric symptoms during a September 2003 examination shortly before his separation from military service. The Veteran's military personnel records reflect the Veteran's service with the strategic missile wing at Malmstrom Air Force Base. The Veteran's statements regarding his service appear to be consistent with the circumstances, conditions, and hardships of his service. As such, he has satisfied the second element of service connection.

The last element of service connection requires medical evidence establishing a linkage between service and the Veteran's current symptoms of the variously diagnosed psychiatric disorders. On this question, there is only evidence in favor of the Veteran's claim. 

While a diagnosis of depression was given on a September 2003 VA examination, an etiological opinion was not provided. 

A private DBQ and examination report is of record dated October 2024. The examiner provided a diagnosis of generalized anxiety disorder. The examiner reviewed the Veteran's claims file and conducted a clinical interview with the Veteran prior to completing the evaluation report. The examiner recorded the Veteran's reports of anxiety symptoms beginning during service while working in missile operations. The Veteran reported that he could never divulge his feelings or symptoms because if he complained of anxiety, he would have lost his career. He reported that his primary duty was to monitor alerts at the ICBM launch control centers and, if he received a valid order, to launch a nuclear ICBM. He recalled feelings of constant emotional stress while on alert duty and serving as a missile combat crew commander as well as the fear of having to execute orders if requested to launch nuclear missiles. The Veteran reported that the possibility was constantly on his mind and provoked a lot of anxiety. 

The examiner further recorded the Veteran's reports of worsening anxiety symptoms related to the September 11th attacks when he was in the DISA (Defense Information Systems Agency) building in the flight path of the plane that hit the Pentagon. The Veteran recalled feeling the wave or vibration caused by the plane flying so low over his building and upon impact. He reported that his operation center was on the top floor of his office building and stood a quarter mile from the Pentagon and recalled being told that the plane flew no more than 100 feet over the building. The Veteran reported that his boss had been at the Pentagon and recalled initial confusion over whether he was still alive or had perished. He noted that he volunteered to be on the night shift that day due to other unknown threats and that his job at the time was monitoring cyber security for the Department of Defense. He reported that he feared for his life and the lives of his colleagues, as they believed they could be next to be attacked and that he still experiences severe anxiety when recalling this frightening experience. 

The examiner opined that it is more likely than not that the Veteran's generalized anxiety disorder is related to his service. The examiner indicated that the Veteran's anxiety symptoms began during his service as a result of the stressful and demanding environment while serving at missile launch control centers at Malmstrom Air Force Base. The examiner noted that the Veteran's symptoms were further exacerbated by his experiences during the September 11th attacks at the Pentagon. The examiner concluded that, as a result of the progression and current symptoms of generalized anxiety, it is their opinion that the Veteran's current symptoms are most
 for his life and the lives of his colleagues, as they believed they could be next to be attacked and that he still experiences severe anxiety when recalling this frightening experience. 

The examiner opined that it is more likely than not that the Veteran's generalized anxiety disorder is related to his service. The examiner indicated that the Veteran's anxiety symptoms began during his service as a result of the stressful and demanding environment while serving at missile launch control centers at Malmstrom Air Force Base. The examiner noted that the Veteran's symptoms were further exacerbated by his experiences during the September 11th attacks at the Pentagon. The examiner concluded that, as a result of the progression and current symptoms of generalized anxiety, it is their opinion that the Veteran's current symptoms are most likely related to his service. While additional rationale was not provided, the whole of the examiner's report is complete in nature and favorable to the Veteran's claim. 

The Board finds that the Veteran has satisfied the third element of service connection. His acquired psychiatric disorder, variously diagnosed as depression and generalized anxiety disorder, has been positively linked to his military service by the October 2024 private examiner. Importantly, the findings of the October 2024 private examiner are not contradicted by other medical evidence of record. 

Accordingly, the Board finds that the evidence of record is in favor of a grant for service connection. In resolving all reasonable doubt in the Veteran's favor, the Board concludes that service connection for an acquired psychiatric disorder is warranted.

7. Entitlement to service connection for a left hip condition

The Veteran contends that he has left hip condition related to his service. Alternatively, he contends that such is secondary to his service-connected musculoskeletal conditions. Available medical evidence includes diagnoses of left hip bursitis, trochanteric bursitis, left hip degenerative joint disease and status-post left hip labral repair. September 2010 and November 2010 Private Treatment Records and February 2013 and February 2020 VA Examinations. These diagnoses satisfy the first element of service connection. 

The Veteran's STRs do not include any complaints of, or treatment for, a left hip condition. The Veteran contends that his left hip problems began during service and that he was referred to orthopedics as part of his retirement physical examination in July 2003. He contends that his left hip condition existed at the time of his retirement physical. March 2010 Statement in Support of Claim and March 2011 VA 21-4142 Authorization for Release of Information. The Board notes that the Veteran reported right hip pain during a September 2003 VA examination, but he did not report left hip symptoms or complaints. With regard to secondary service connection, the Board notes that the Veteran has been service connected for a left knee condition from April 2019, a lumbar spine condition from December 2003, and a right hip condition from December 2009. 

During an October 2010 private treatment visit, the Veteran reported pain in both hips since 2003. 

A June 2010 VA examiner only provided right hip diagnosis and history. However, the examination showed left hip pain with range of motion testing and the examiner clarified that this was related to a left hip strain. 

Another VA examination was obtained in February 2012, but the examiner only provided right hip diagnoses. However, the examiner recorded the Veteran's history of arthritis and labral tears in both hips as well as constant pain in both hips, with the left worse than the right. 

A private medical opinion was received in July 2012. The examiner opined that the Veteran's left hip problem is not at least as likely as not caused by his right hip problem. The examiner explained that the Veteran's pain is not caused by his other hip but is the same process and may be aggravated by the other hip if unable to compensate due to pain. 

During a May 2012 private treatment visit, the provider noted that the Veteran had developed left hip symptoms over time in conjunction with a gradual worsening of his right hip condition. The examiner provided an unclear opinion, as the examiner opined that it is "more likely than not that the similar symptoms of the right hip, the similar symptoms that he has in the hip as the right, are service connected." It is unclear what the examiner intended to opine, such as whether the examiner meant to opine that the symptoms of the Veteran's left hip are similar to those in the right hip and are also related to service or whether the examiner intended something different. 

A VA examination is of record dated February 2013. The examiner provided a diagnosis of bilateral hip degenerative joint disease. The examiner recorded the Veteran's reports of symptoms beginning in 2003 and that during his final assignment he began favoring his left hip. An etiological opinion was not provided. 

A VA medical opinion was obtained in June 2013. The
 symptoms of the right hip, the similar symptoms that he has in the hip as the right, are service connected." It is unclear what the examiner intended to opine, such as whether the examiner meant to opine that the symptoms of the Veteran's left hip are similar to those in the right hip and are also related to service or whether the examiner intended something different. 

A VA examination is of record dated February 2013. The examiner provided a diagnosis of bilateral hip degenerative joint disease. The examiner recorded the Veteran's reports of symptoms beginning in 2003 and that during his final assignment he began favoring his left hip. An etiological opinion was not provided. 

A VA medical opinion was obtained in June 2013. The examiner indicated that the Veteran's current left hip disorder is a separate and new condition which developed years after discharge from service. The examiner remarked that there is no objective documentation of bilateral hip degenerative joint disease and no evidence of a chronic hip disorder in service. The examiner noted that, while the Veteran's right hip pain was noted during his 2003 separation examination, there is no documentation of chronic gait abnormality that would account for his diagnosed left hip bursitis. As such, the examiner opined that the Veteran's left hip condition is less likely than not due to or the result of his service-connected right hip condition. Further rationale was not provided. 

Another VA examination is of record dated June 2019. While the examiner only provided a diagnosis for the right hip, the examiner recorded the Veteran's reports that his left hip symptoms onset in 2005. The Veteran reported that his left hip began hurting in the years after service and was always a little worse than the right. An etiological opinion was not provided. 

Another VA examination is of record dated February 2020. The examiner provided diagnoses of bilateral hip osteoarthritis and status-post bilateral hip labral repair. However, the examiner did not provide any medical history related to the Veteran's left hip. The examiner remarked that, for the Veteran's VA established diagnosis of right hip degenerative joint disease limitation of extension, the diagnosis is changed, and it is a progression of the previous diagnosis. The examiner remarked that the Veteran's condition has progressed to include the left hip degenerative arthritis and status-post bilateral hip labral repair. An etiological opinion was not provided. 

While a January 2023 VA hip conditions examination is of record, the examiner only provided a right hip diagnosis and no range of motion measurements of the left hip were provided. 

A private examination is of record dated October 2024. The examiner provided a diagnosis of pain of the left hip. The Veteran reported that he has suffered from progressive left hip pain since the involvement of the right hip, left knee, and lumbar spine. The examiner noted that the Veteran's pain is daily in varying degrees and intensifies with standing and walking. Upon examination, the examiner noted that the Veteran had severe decreased range of motion with flexion, internal rotation, and external rotation. The examiner recommended further evaluation with an orthopedic surgeon. The examiner opined that it is as likely as not that the Veteran's left hip condition is directly and causally related to the constant and chronic compensation and adaptation to the weight shifting and altered gait caused by the service-connected right hip, left knee, and lumbar spine conditions. The examiner further opined that it is as likely as not that the Veteran's left hip condition is directly and causally related to his military service and that such is a permanent and progressive condition. While further rationale was not provided, the whole of the examination report is favorable to the Veteran's claim and the Board finds that the private examiner, a chiropractor, is qualified to provide an opinion regarding the Veteran's altered gait related to his service-connected musculoskeletal conditions and how such as resulted in his left hip condition. 

A VA examination was most recently obtained in December 2024. However, the examiner only provided a diagnosis of and medical history for a right hip condition and failed to assess the Veteran's left hip. 

The Board ascribes more weight to the October 2024 private opinion of record and finds the VA opinions to be of little probative value. The VA examiners largely failed to consider the Veteran's left hip condition or failed to provide etiological opinions. Only the June 2013 VA examiner provided a nexus opinion, but the examiner failed to provide adequate rationale in support of the opinion provided. In contrast, the October 2024 private opinion establishes that the Veteran's left hip condition is proximately due to his service-connected left knee, right hip, and lumbar spine conditions.

Accordingly, the Board finds that the evidence of record is, at minimum, in equipoise regarding the question of secondary service connection. The benefit of the doubt will be conferred in the Veteran's favor, and the Board finds that his left hip
 and finds the VA opinions to be of little probative value. The VA examiners largely failed to consider the Veteran's left hip condition or failed to provide etiological opinions. Only the June 2013 VA examiner provided a nexus opinion, but the examiner failed to provide adequate rationale in support of the opinion provided. In contrast, the October 2024 private opinion establishes that the Veteran's left hip condition is proximately due to his service-connected left knee, right hip, and lumbar spine conditions.

Accordingly, the Board finds that the evidence of record is, at minimum, in equipoise regarding the question of secondary service connection. The benefit of the doubt will be conferred in the Veteran's favor, and the Board finds that his left hip condition is secondary to his service-connected left knee, right hip, and lumbar spine conditions. Accordingly, service connection for a left hip condition is warranted.

8. Entitlement to service connection for a thoracic spine condition, to include as secondary to the service-connected low back condition

The Veteran contends that he has a thoracic spine condition related to his military service. He contends that his condition began during his active service. March 2010 Statement in Support of Claim. Alternatively, he contends that he has a thoracic spine condition secondary to his service-connected low back condition. After a thorough review of the evidence of record, the Board concludes that he does not have a separately diagnosed thoracic spine condition. Initially, and in this regard, the Board notes that medical records associated with the file do not reflect a diagnosis of, or treatment for, a thoracic spine condition. 

The Veteran's STRs do not include any complaints of, or treatment for, a thoracic spine condition during service. While the Veteran reported recurrent back pain or any back problem on his June 2003 retirement examination, this was described as lower back pain. 

While the Veteran's private treatment records include multiple complaints of back pain, this was consistently described as lower back pain rather than thoracic pain. 

A September 2003 X-ray of the lumbar spine revealed a diagnosis of degenerative disease to the L3-4 and T12-L1. A thoracic spine X-ray was not obtained. 

The Veteran was accorded a VA examination in February 2010. While the Veteran reported pain and tenderness to the back, this was indicated in the lumbar region. The examiner noted that there was no change in the Veteran's established diagnosis of degenerative arthritis of the lumbar spine and a thoracic spine diagnosis was not indicated. 

Another VA examination is of record dated March 2011. However, the Veteran only reported lower back pain. The examination of the thoracolumbar spine revealed only tenderness to the L2 and L3 as well as with spinal contour. The examiner noted that there was no change in the Veteran's established diagnosis of degenerative arthritis of the lumbar spine and a thoracic spine diagnosis was not indicated.

Another VA examination is of record dated February 2013. Again, only a lumbar spine diagnosis was provided, and no symptoms of a thoracic spine condition were indicated. 

The Veteran was accorded another VA examination in February 2020. The examiner provided a diagnosis of degenerative arthritis of the spine. The examiner recorded current symptoms of lower back pain and shooting pain down the left leg, toes, and feet. The examiner noted that there was no change in the Veteran's established diagnosis of degenerative arthritis of the lumbar spine and a thoracic spine diagnosis was not indicated.

Another VA examination is of record dated January 2023. The examiner provided a diagnosis of degenerative arthritis of the spine as well as bilateral lumbar radiculopathy. The examiner noted that the Veteran's condition has progressed and the frequency and severity of his symptoms have increased. The Veteran reported current symptoms of pain, stiffness, numbness, and tingling. The examiner remarked that there is a worsening of the Veteran's symptoms, but there is no change to his service-connected diagnosis and no additional diagnoses, including a thoracic spine diagnosis, have been rendered. 

A private examination is of record dated October 2024. The examiner provided a diagnosis of pain of the thoracic spine. The Veteran reported that since the onset of low back pain, he has suffered from progressive pain and stiffness in the thoracic region which concentrates between the scapulae. He reported that his pain is daily in varying degrees and has increased with time. Upon examination, the examiner indicated that the thoracic erector spinae bilaterally are hypertonic and there is reduced segmental motion of segments T5-T10. The examiner opined that it is as likely as not that his thoracic spine condition is directly and causally related to the Veteran's service-connected low back condition as an adaptive and compensatory biomechanical mechanism. The examiner further remarked that it is accordingly as likely as not that
 diagnosis of pain of the thoracic spine. The Veteran reported that since the onset of low back pain, he has suffered from progressive pain and stiffness in the thoracic region which concentrates between the scapulae. He reported that his pain is daily in varying degrees and has increased with time. Upon examination, the examiner indicated that the thoracic erector spinae bilaterally are hypertonic and there is reduced segmental motion of segments T5-T10. The examiner opined that it is as likely as not that his thoracic spine condition is directly and causally related to the Veteran's service-connected low back condition as an adaptive and compensatory biomechanical mechanism. The examiner further remarked that it is accordingly as likely as not that the same is directly and causally related to his military service. The examiner failed to provide any rationale in support of the opinion provided. Furthermore, there is no indication in the examination report that the examiner reviewed the claims file, performed an examination of the Veteran, or conducted an interview with the Veteran and it is unclear to the Board how the examiner reached the conclusions provided. As such, the Board finds the October 2024 private examination to be less probative and inadequate for adjudication purposes. 

The Veteran was most recently accorded a VA examination in December 2024. The examiner provided a diagnosis of degenerative arthritis. The Veteran reported that his condition has gotten worse as he now feels pain in the lower and mid-back. The Veteran reported current symptoms of constant dull ache that becomes sharp with increased physical activity and additionally reported difficulty bending over and pain with prolonged sitting. The examiner opined that it is less likely than not that the Veteran's thoracic spine condition is proximately due to or the result of his service-connected low back condition. 

The examiner remarked that X-rays from September 2003 noted degenerative disease in the thoracic and lumbar spine. However, the Board observes that the September 2003 X-ray was only of the Veteran's lumbar spine and a specific diagnosis of degenerative disease of the thoracic spine was not indicated. The examiner explained that the nature of arthritis is to progressively get worse over time and that such is consistent with the Veteran's subjective history. As such, the examiner determined that this can all be placed under the diagnosis of degenerative arthritis of the spine for which the Veteran is already service connected. The examiner explained that degenerative arthritis is a progressive disease that occurs as one ages and that the Veteran's degenerative changes in both the thoracic and lumbar spine are likely due to the wear and tear his entire spine has suffered over time, but the degenerative arthritis in the lumbar spine did not cause the degenerative changes in the thoracic spine. An aggravation opinion was not provided. 

The Board finds that the medical evidence of record fails to demonstrate a separately diagnosed thoracic spine condition. While the Veteran reported pain to the mid-back along with difficulty bending over, the December 2024 VA examiner explained that the Veteran's contended thoracic spine condition is a manifestation of the Veteran's degenerative arthritis of the lumbar spine. The other competent medical evidence of record fails to demonstrate that the Veteran has a separately diagnosed thoracic spine condition.

The threshold requirement for service connection is competent evidence of the existence of the claimed disability at some point during the appeal. McClain v. Nicholson, 21 Vet. App. 319 (2007), Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). While the Board recognizes the Veteran's sincere belief in his thoracic spine condition claim, the most competent evidence of record does not show that he has had a diagnosis of a thoracic spine condition at any time during the current appeal. Thus, the record does not support service connection for a thoracic spine condition. In reaching this determination, the Board is mindful that all reasonable doubt is to be resolved in the Veteran's favor. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). However, because the persuasive weight of the evidence is against the claim, it must be denied. 

9. Entitlement to service connection for a left heel condition

The Veteran contends that he has a left heel condition related to his military service. However, he has not alleged any in-service event, incident, or injury. After a thorough review of the evidence of record, the Board concludes that the Veteran does not have a separately diagnosed left heel condition.

The Veteran's STRs do not include any complaints of, or treatment for, a left heel condition during service. 

A private evaluation is of record dated October 2024. The examiner provided a diagnosis of pain of the left heel. The Veteran reported that, since the onset of the left knee, right hip, and lumbar spine conditions, he has suffered from progressive left heel pain.
9. Entitlement to service connection for a left heel condition

The Veteran contends that he has a left heel condition related to his military service. However, he has not alleged any in-service event, incident, or injury. After a thorough review of the evidence of record, the Board concludes that the Veteran does not have a separately diagnosed left heel condition.

The Veteran's STRs do not include any complaints of, or treatment for, a left heel condition during service. 

A private evaluation is of record dated October 2024. The examiner provided a diagnosis of pain of the left heel. The Veteran reported that, since the onset of the left knee, right hip, and lumbar spine conditions, he has suffered from progressive left heel pain. He reported that the pain is daily in varying degrees and intensifies with standing and walking. The examiner remarked that there is tenderness on palpitation. The examiner opined that it is as likely as not that his left heel condition is directly and causally related to the Veteran's constant and chronic compensation and adaptation to the weight shifting and altered gait caused by the left knee, right hip, and lumbar spine conditions. The examiner further remarked that it is as likely as not that the same is directly and causally related to his military service. The examiner failed to provide any rationale in support of the opinion provided. Furthermore, there is no indication in the examination report that the examiner reviewed the claims file, performed an examination of the Veteran, or conducted an interview with the Veteran and it is unclear to the Board how the examiner reached the conclusions provided. As such, the Board finds the October 2024 private examination to be less probative and inadequate for adjudication purposes. 

The Veteran was accorded a VA examination in December 2024. No left heel diagnosis was provided. The examiner recorded the Veteran's reports of left heel pain shortly after knee surgery and the Veteran described the pain as a constant "burning needle sensation" in the left heel. The Veteran reported functional loss and functional impairment which was described as limited walking. Pain was noted on physical examination and was noted to contribute to functional loss. The Veteran's left heel was additionally observed to be very tender to palpation. The examiner remarked that the Veteran's current symptoms are more neurological than musculoskeletal. The examiner indicated that, as such, the Veteran's current symptoms are more consistent with his service-connected left lower extremity radiculopathy. 

The examiner opined that it is less likely than not that the Veteran's left heel condition is proximately due to or the result of the Veteran's service-connected condition. The examiner explained that the Veteran's current complaint of left heel burning sensation is a symptom of the Veteran's already service-connected left lower extremity radiculopathy. The examiner noted that there is no new diagnosis and therefore his contended left heel condition cannot be attributed to a service-connected condition. 

A June 2025 private treatment record indicates that the Veteran does not have any calcaneal heel spurs or any issue with the heel on the left. 

The Board finds that the medical evidence of record fails to demonstrate a separately diagnosed left heel condition. While the Veteran reported pain to the left heel and that his pain limits his ability to walk, the December 2024 VA examiner explained that the Veteran's left heel complaint is a symptom of his already service-connected left lower extremity radiculopathy. The other medical evidence of record fails to demonstrate that the Veteran has a separately diagnosed left heel condition.

The threshold requirement for service connection is competent evidence of the existence of the claimed disability at some point during the appeal. McClain v. Nicholson, 21 Vet. App. 319 (2007), Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). While the Board recognizes the Veteran's sincere belief in his left heel condition claim, the most competent evidence of record does not show that he has had a diagnosis of a left heel condition at any time during the current appeal. Thus, the record does not support service connection for a left heel condition. In reaching this determination, the Board is mindful that all reasonable doubt is to be resolved in the Veteran's favor. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). However, because the persuasive weight of the evidence is against the claim, it must be denied. 

REASONS FOR REMAND

1. Entitlement to a compensable rating for the service-connected right hip osteoarthritis is remanded.

A private examination is of record dated October 2024. The examiner indicated that the Veteran has suffered from an extension of his condition. The examiner noted that the Veteran suffers from progressive right hip pain which is daily and of varying degrees. The examiner indicated that his pain intensifies with standing and walking. On examination, moderate
 to be resolved in the Veteran's favor. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). However, because the persuasive weight of the evidence is against the claim, it must be denied. 

REASONS FOR REMAND

1. Entitlement to a compensable rating for the service-connected right hip osteoarthritis is remanded.

A private examination is of record dated October 2024. The examiner indicated that the Veteran has suffered from an extension of his condition. The examiner noted that the Veteran suffers from progressive right hip pain which is daily and of varying degrees. The examiner indicated that his pain intensifies with standing and walking. On examination, moderate decreased range of motion to pain was noted with flexion, internal rotation, and external rotation, although the examiner did not provide measurements. The examiner noted that further evaluation with an orthopedic surgeon was recommended. The examiner's assessment failed to take the rating criteria into consideration in assessing the severity of the Veteran's condition. As such, the Board finds the October 2024 private examination to be less probative and inadequate for rating purposes. 

The Veteran was most recently accorded a VA examination in December 2024. Upon review, the Board finds that a remand is necessary to obtain an examination compliant with the requirements set forth by the Court in Correia v. McDonald, 28 Vet. App. 158 (2016). 

In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims emphasized that 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weightbearing and non-weightbearing. Such findings were not provided in the December 2024 VA examination. 

Although the December 2024 VA examiner indicated that the Veteran's active and passive range of motion were the same, the examination report includes only one set of range of motion measurements and did not include range of motion testing in weightbearing and nonweight-bearing in compliance with Correia. Such amounts to only a cursory consideration of Correia, and such renders the examination inadequate for rating purposes.

Furthermore, the December 2024 VA examiner remarked that the Veteran had pain with active motion and passive motion, but failed to indicate at which point this pain was observed. The examiner failed to note at which point the Veteran experienced pain during range of motion testing, to include whether or not the pain amounts to favorable or unfavorable ankylosis so as to warrant a higher evaluation under the rating schedule. DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011).

Failing to obtain an adequate examination and relying on an inadequate examination is a pre-decisional duty to assist error. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). This pre-decisional duty-to-assist error should be remedied on remand by providing the Veteran a new VA examination that adequately addresses the current severity of the Veteran's service-connected right hip condition.

2. Entitlement to service connection for bilateral hearing loss is remanded.

The Veteran contends that he has bilateral hearing loss related to his service as a missile launch crew member. He contends that hearing loss was identified during his retirement physical in 2003. In support of his contentions, the Veteran referred to multiple studies and government reports which discuss the relationship between acoustic trauma during military service and hearing loss. November 2014 Correspondence. 

During a September 2003 VA examination, the Veteran reported trouble hearing when people talk softly or when there is background noise and he reported that this first began 3 to 4 years prior. Audiological testing did not reveal hearing loss for VA purposes. 

While hearing loss for VA purposes was shown in the left ear on a November 2014 VA examination, an etiological opinion was not provided. 

A private examination is of record dated October 2024. The examiner recorded the Veteran's reports of acoustic trauma during service from serving in the missile launch control center. The examiner remarked that the Veteran has suffered from progressive bilateral hearing loss. While the examiner indicated that the Veteran's hearing was tested, the examiner did not provide audiological findings and suggested that the Veteran be asked to attend a puretone audiogram. The examiner concluded that the Veteran has an estimated hearing loss of 40 percent in the right ear and 40 percent in the left ear. The examiner concluded that it is as likely as not that the Veteran's bilateral hearing loss is directly and causally related to the acoustic trauma experienced during service and, as such, it is as likely as not that the same is directly and causally related to
. The examiner recorded the Veteran's reports of acoustic trauma during service from serving in the missile launch control center. The examiner remarked that the Veteran has suffered from progressive bilateral hearing loss. While the examiner indicated that the Veteran's hearing was tested, the examiner did not provide audiological findings and suggested that the Veteran be asked to attend a puretone audiogram. The examiner concluded that the Veteran has an estimated hearing loss of 40 percent in the right ear and 40 percent in the left ear. The examiner concluded that it is as likely as not that the Veteran's bilateral hearing loss is directly and causally related to the acoustic trauma experienced during service and, as such, it is as likely as not that the same is directly and causally related to his military service. The examiner failed to provide any rationale in support of the opinion provided. Furthermore, there is no indication in the examination report that the examiner reviewed the claims file, performed an examination of the Veteran, or conducted an interview with the Veteran and it is unclear to the Board how the examiner reached the conclusions provided. Additionally, the Board observes that the examiner is a chiropractor who has not been shown to be qualified to assess the nature and etiology of audiological conditions. A chiropractor generally does not have training, education, or experience in medicine or in relation to medical diseases. See American Chiropractic Association website, Origins and history of chiropractic, www.acatoday.org/about/history-of-chiropractic/. The Veteran has not offered any evidence to establish that the October 2024 private examiner has such training, education, or experience. As such, the Board finds the October 2024 private examination to be less probative and inadequate for adjudication purposes. 

A private audiogram is of record dated May 2025. While testing reveals bilateral hearing loss for VA purposes and the examiner noted the Veteran's contended military noise exposure, an etiological opinion was not provided. 

The Board finds a remand is necessary to obtain a VA nexus opinion on the nature and etiology of the Veteran's hearing loss. VA's duty to assist includes, when necessary, conducting a thorough and comprehensive medical examination. Under 38 U.S.C. § 5103A(d)(2), VA must provide a medical examination and, or, obtain a medical opinion, when there is (1) competent evidence that the Veteran has a current disability (or persistent or recurrent symptoms of a disability); (2) evidence establishing that he suffered an event, injury or disease in service or has a disease or symptoms of a disease within a specified presumptive period; (3) an indication the current disability or symptoms may be associated with service; and (4) there is not sufficient medical evidence to make a decision. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third element, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. Id. at 83. 

A VA medical opinion has not been obtained for the Veteran's bilateral hearing loss, despite having been diagnosed with bilateral hearing loss for VA purposes and despite his contention that such is related to service. The Veteran has not been afforded a VA examination for an acquired psychiatric disorder, despite having been diagnosed with various psychiatric disorders and despite his contention that such is related to his service. No adequate medical opinion is of record in an eligible evidence window addressing the etiology of the Veteran's bilateral hearing loss. This failure to obtain an etiological opinion constitutes a pre-decisional duty to assist error. McLendon v. Nicholson, 20 Vet. App. 79 (2006). This duty to assist error should be remedied on remand by obtaining a VA medical opinion to address the nature and etiology of the Veteran's bilateral hearing loss.

3. Entitlement to service connection for melanoma is remanded.

The Veteran contends that he has melanoma related to his military service. He contends that he was exposed to radiation while serving at missile launch sites and that his melanoma is related to this exposure. November 2024 Supplemental Claim. He has reported that he was in charge of launching nuclear missiles in the event the order was given. The Veteran provided information regarding his potential exposures in December 2024. He reports that, as a deputy/missile combat crew member, he performed 175 alerts at ICBM launch control centers which were known to have PCBs (polychlorinated biphenyls) in the equipment, floor tiles containing asbestos, lead, and other chemicals. December 2024 Radiation Risk Activity Worksheet.  

Service connection based on exposure to ionizing radiation in service can be established in any of three different ways. See Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App
 was in charge of launching nuclear missiles in the event the order was given. The Veteran provided information regarding his potential exposures in December 2024. He reports that, as a deputy/missile combat crew member, he performed 175 alerts at ICBM launch control centers which were known to have PCBs (polychlorinated biphenyls) in the equipment, floor tiles containing asbestos, lead, and other chemicals. December 2024 Radiation Risk Activity Worksheet.  

Service connection based on exposure to ionizing radiation in service can be established in any of three different ways. See Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). First, there are diseases that are presumptively service connected in radiation-exposed Veterans under 38 U.S.C. § 1112(c) and 38 C.F.R. § 3.309(d). Second, service connection can be established under 38 C.F.R. § 3.303(d) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311 if the disorder at issue is a radiogenic disease. Third, direct service connection can be established under 38 C.F.R. § 3.303(d) by showing that the disease was incurred during or aggravated by service without regard to the statutory presumptions. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994).

Certain conditions are presumed to be service-connected when they manifest in "radiation-exposed Veterans." 38 C.F.R. § 3.309(d)(1), (2). However, the term "radiation-exposed Veterans" applies only to Veterans who participated in specific radiation-risk activities, including onsite participation in a test involving atmospheric detonation of a nuclear device; certain service in or near Hiroshima or Nagasaki, Japan; service on the grounds of a gaseous diffusion plant in Paducah, Kentucky, Portsmouth, Ohio or in the area identified as K25 at Oak Ridge, Tennessee; service on Amchitka Island, Alaska; and service that would qualify for inclusion as a member of the Special Exposure Cohort if performed as an employee of the Department of Energy. 38 C.F.R. § 3.309(d)(3).

The Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxins Act (PACT Act) expanded the presumption of radiation exposure to Veterans who participated in (1) the nuclear cleanup of Enewetak Atoll from January 1, 1977, to December 31, 1980, (2) the nuclear response effort near Palomares, Spain from January 17, 1966, to March 31, 1967, and (3) the nuclear response effort near Thule, Greenland from January 21, 1968, to September 25, 1968. See 38 U.S.C. § 1112(c)(3)(B)(v-viii).

The Veteran has not alleged, and his records do not reflect, that his service included any of the above circumstances. Therefore, he is not a "radiation-exposed Veteran" within the meaning of the regulations, and the associated presumptions are not applicable.

Although the Veteran does not qualify as a "radiation-exposed Veteran" under 38 C.F.R. § 3.309(d)(3), he may still benefit from the special development procedures provided in 38 C.F.R. § 3.311 if he suffers from a radiogenic disease and claims exposure to ionizing radiation in service. Under 38 C.F.R. § 3.311, "radiogenic disease" means a disease that may be induced by ionizing radiation and shall include the following: (i) All forms of leukemia, except chronic lymphatic (lymphocytic) leukemia; (ii) Thyroid cancer; (iii) Breast cancer; (iv) Lung cancer; (v) Bone cancer; (vi) Liver cancer; (vii) Skin cancer; (viii) Esophageal cancer; (ix) Stomach cancer; (x) Colon cancer; (xi) Pancreatic cancer; (xii) Kidney cancer; (xiii) Urinary bladder cancer; (xiv) Salivary gland cancer; (xv) Multiple myeloma; (xvi) Posterior subcapsular cataracts; (xvii) Non-malignant thyroid nodular disease; (xviii) Ovarian cancer; (xix) Parathyroid adenoma; (xx) Tumors of the brain and central nervous system; (xxi) Cancer of
) Bone cancer; (vi) Liver cancer; (vii) Skin cancer; (viii) Esophageal cancer; (ix) Stomach cancer; (x) Colon cancer; (xi) Pancreatic cancer; (xii) Kidney cancer; (xiii) Urinary bladder cancer; (xiv) Salivary gland cancer; (xv) Multiple myeloma; (xvi) Posterior subcapsular cataracts; (xvii) Non-malignant thyroid nodular disease; (xviii) Ovarian cancer; (xix) Parathyroid adenoma; (xx) Tumors of the brain and central nervous system; (xxi) Cancer of the rectum; (xxii) Lymphomas other than Hodgkin's disease; (xxiii) Prostate cancer; and (xxiv) Any other cancer. 38 C.F.R. § 3.311(b)(2).

Under 38 C.F.R. § 3.311, if a radiogenic disease such as skin cancer first became manifest after service and 5 years or more after the alleged in-service exposure to ionizing radiation, and service connection cannot be granted under the presumptive provisions of 38 C.F.R. § 3.307 or 38 C.F.R. § 3.309, a dose assessment must be conducted prior to adjudication of the claim. See 38 C.F.R. § 3.311(a), (b)(2)(xxii). A review of the Veteran's record confirms that his melanoma manifested more than 5 years after the Veteran's reported exposure but does not reveal a dose assessment.

The AOJ's failure to obtain a dose assessment and develop the claim in accordance with 38 C.F.R. § 3.311 constitutes a pre-decisional duty to assist error. As such, a remand is warranted for corrective action to include obtaining a dose assessment to determine the Veteran's level, if any, of exposure to ionizing radiation during service. 

Additionally, as noted above, the Veteran also contends that he was exposed to asbestos, PCBs, lead, and other chemicals at ICBM launch control centers. In support of his claim, the Veteran submitted portions of a missile community cancer study. December 2024 Correspondence.  

The Veteran's STRs do not include any complaints of or treatment for melanoma during service. His military personnel records reflect his service with the strategic missile wing at Malmstrom Air Force Base. The Veteran's claims file includes a diagnosis of melanoma. See October 2024 Private Examination. 

The record does not indicate that AOJ attempted to verify the Veteran's contended exposure to hazardous chemicals, including PCB, asbestos, lead, and other chemicals while in service. The AOJ's failure to seek verification of the Veteran's contended exposure to hazardous materials is a pre-decisional duty to assist error. As such, a remand is necessary to attempt to verify the Veteran's contended exposure to hazardous materials during his service. 

The matters are REMANDED for the following action:

1. Conduct all necessary development to request any available records concerning the Veteran's contended exposure to ionizing radiation and develop the claim in accordance with 38 C.F.R. § 3.311.

2. Conduct all necessary development to determine whether the Veteran had exposure to ionizing radiation during service, to include his service at Malmstrom Air Force Base.

3. Contact all appropriate entities and request verification of any potential exposure to hazardous chemicals other than radiation during the Veteran's service, to include seeking information as to whether he was exposed to asbestos, PCBs, lead, or other chemicals. Information should be requested regarding any available information about the types of hazardous materials that he would have been exposed to during service. If any repository is unable to furnish such records or provide a response regarding hazardous materials, request such to identify any other resource for such information. Document all efforts to obtain this information as well as any associated responses in the claims file.

4. Schedule the Veteran for a VA examination to determine the current severity of his service-connected right hip condition. The entire claims file, including a copy of this remand, should be made available to, and reviewed by, the examiner. Any indicated tests and studies must be accomplished. All clinical findings found on examination to be associated with this disability must be reported in detail.

The examiner should include range of motion testing for pain in active and passive motion of the Veteran's right hip as well as weight-bearing and non-weightbearing and address his pain with range of motion-to the extent possible. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he/she should clearly explain why that is so.?In reporting the results of range of motion testing, the examiner should specifically identify the points, if
-connected right hip condition. The entire claims file, including a copy of this remand, should be made available to, and reviewed by, the examiner. Any indicated tests and studies must be accomplished. All clinical findings found on examination to be associated with this disability must be reported in detail.

The examiner should include range of motion testing for pain in active and passive motion of the Veteran's right hip as well as weight-bearing and non-weightbearing and address his pain with range of motion-to the extent possible. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he/she should clearly explain why that is so.?In reporting the results of range of motion testing, the examiner should specifically identify the points, if any, at which pain begins. 

Also, the examiner should describe any functional limitation due to pain, weakened movement, excess fatigability, pain with use, or incoordination. Additional limitation of motion during flare-ups and following repetitive use due to limited motion, excess motion, fatigability, weakened motion, incoordination, or painful motion must also be noted. If the Veteran describes flare-ups of the pain, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups. All losses of function due to problems such as pain should be equated to additional degrees of limitation of flexion and extension beyond that shown clinically.? 

Should the examiner be unable to offer such an opinion without resorting to speculation based on the fact that the examination was not performed during a flareup, the examiner is directed to do all that reasonably can be done to become informed before such a conclusion, to include ascertaining adequate information-i.e., frequency, duration, characteristics, severity, or functional loss-regarding the Veteran's flareups by alternative means.? 

The examiner is also advised that the Veteran is competent to report his symptoms and history and that such reports must be acknowledged and considered in formulating any opinion. A clear explanation for all opinions would be helpful, as well as a rationale for all opinions rendered, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner is unable to provide an opinion, he or she should explain why.

5. Obtain a VA medical opinion from an appropriate clinician to determine the etiology of the Veteran's bilateral hearing loss. The record must be made available to, and be reviewed by, the VA examiner in conjunction with this evaluation. If deemed necessary, the Veteran should be scheduled for an examination. 

After reviewing the claims file, the examiner is asked to opine as to whether it is at least as likely as not that the Veteran's bilateral hearing loss is related to an in-service injury, event, or disease, including as due to his service as a missile launch crew member? 

In providing the requested opinion, the examiner is advised that the Veteran is competent to report his symptoms and history and that such reports must be acknowledged and considered in formulating all opinions. A clear explanation for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner is unable to provide an opinion, he or she should explain why.

 

 

Marcus N. Fulton

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Goreham, A.

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.