HEMORRHOIDS

TIMOTHY COTHREL · 2026 · Case ID: A26022717

MIXED

Summary

The veteran, who served in the United States Marine Corps from June 1997 to June 2001, appeals a June 2025 rating decision. The veteran sought a compensable rating for hemorrhoids and left ear hearing loss, both of which were denied. Service connection for pseudofolliculitis barbae (PFB) was granted at 10%, along with a separate rating for facial scarring secondary to PFB. Service connection for left shoulder pain was granted based on a chiropractor's opinion, which the Board found persuasive despite the lack of VA examination. Service connection for a low back condition was granted, and secondary service connection for bilateral lower extremity radiculopathy was also granted, based on the Veteran's reports and a chiropractor's opinion. The Board remanded claims for glossopharyngeal nerve damage, sleep apnea, migraine headaches, and hypertension due to inadequate VA examinations or opinions.

Rationale

Amended DC 7336 criteria not met; Symptoms do not approximate criteria for compensable rating; Benefit of doubt doctrine not applicable

Service Branch

MARINE CORPS

Special Benefit

NO SPECIAL BENEFIT

Diagnostic Code

7336

Docket No.

250701-559392

Full Decision Text

Citation Nr: A26022717
Decision Date: 03/12/26 Archive Date: 03/12/26

DOCKET NO. 250701-559392
DATE: March 12, 2026

ORDER

Entitlement to a compensable rating for the Veteran's service-connected hemorrhoids is denied.

Entitlement to a compensable rating for the Veteran's service-connected left ear hearing loss is denied.

Entitlement to a compensable 10 percent rating for the Veteran's service-connected pseudofolliculitis barbae is granted.

Entitlement to a separate disability rating for facial scars due to pseudofolliculitis barbae is granted, effective December 2, 2024.

Entitlement to service connection for left shoulder pain is granted.

Entitlement to service connection for low back condition is granted.

Entitlement to service connection for right lower extremity radiculopathy, to include as secondary to the Veteran's back condition, is granted.

Entitlement to service connection for left lower extremity radiculopathy, to include as secondary to the Veteran's back condition, is granted.

REMANDED

1. Entitlement to service connection for glossopharyngeal nerve damage caused by tonsillectomy is remanded.

2. Entitlement to service connection for sleep apnea is remanded.

3. Entitlement to service connection for migraine headaches is remanded.

4. Entitlement to service connection for hypertension is remanded.

FINDINGS OF FACT

1. The Veteran's hemorrhoids did not manifest as prolapsed internal hemorrhoids with two or less episodes per year of thrombosis; or external hemorrhoids with three or more episodes per year of thrombosis.

2. The Veteran had no worse than Level II hearing loss, left ear.

3. The Veteran's pseudofolliculitis barbae involved taking Intermittent systemic therapy for a total duration of less than 6 weeks over the past 12-month period throughout the period on appeal.

4. The Veteran's pseudofolliculitis barbae resulted in scarring effective December 2, 2024.

5. The Veteran's left shoulder pain began in service.

6. The Veteran's low back condition began in service.

7. The Veteran's right lower extremity radiculopathy was caused by his service-connected low back condition.

8. The Veteran's left lower extremity radiculopathy was caused by his service-connected low back condition.

CONCLUSIONS OF LAW

1. The criteria for entitlement to an initial compensable rating for service-connected hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.114 Diagnostic Code 7336 (effective May 19, 2024).

2. The criteria for entitlement to a compensable rating for hearing loss, left ear, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.85, 4.86, Diagnostic Code (DC) 6100.

3. The criteria for an initial compensable 10 percent rating for pseudofolliculitis barbae are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321. 4.1, 4.3, 4.118.

4. The criteria for service connection for scar as secondary to pseudofolliculitis barbae are met effective December 2, 2024. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

5. The criteria for service connection for left shoulder pain are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

6. The criteria for service connection for low back conditions are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

7. The criteria for service connection for left lower radiculopathy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

8. The criteria for service connection for right lower radiculopathy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38
, 3.303.

6. The criteria for service connection for low back conditions are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

7. The criteria for service connection for left lower radiculopathy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

8. The criteria for service connection for right lower radiculopathy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Marine Corps from June 1997 to June 2001.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2025 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In the July 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.

Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran [or representative] with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included in this decision.

However, because the Board is remanding claims, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Increased Ratings

Disability ratings are based on a schedule of reductions in earning capacity from specific injuries or combinations of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations.?38?U.S.C. §?1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability.?38?C.F.R. §?4.1. The Board must evaluate all evidence in arriving at a decision regarding an increased rating.?38?C.F.R. §§?4.2, 4.6.

Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned.?38?C.F.R. §?4.7.

The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Hart v. Mansfield,?21?Vet. App.?505?(2007).

The evaluation of the same disability under several diagnostic codes (DCs), known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative of, or overlapping with, the symptomatology of the other condition. See?38?C.F.R. §?4.14; see also Esteban v. Brown,?6?Vet. App.?259, 261-62?(1994).

1. Entitlement to a compensable rating for the Veteran's service-connected hemorrhoids denied.

The Veteran asserts entitlement to a compensable rating for hemorrhoids. His hemorrhoids are currently rated noncompensable under Diagnostic Code 7336. The Board notes that the criteria
(DCs), known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative of, or overlapping with, the symptomatology of the other condition. See?38?C.F.R. §?4.14; see also Esteban v. Brown,?6?Vet. App.?259, 261-62?(1994).

1. Entitlement to a compensable rating for the Veteran's service-connected hemorrhoids denied.

The Veteran asserts entitlement to a compensable rating for hemorrhoids. His hemorrhoids are currently rated noncompensable under Diagnostic Code 7336. The Board notes that the criteria for Diagnostic Code 7336 were amended, effective May 19, 2024. See Appendix A to Part 4, Title 38. These new regulations apply to all applications for benefits received by VA or that are pending before the AOJ on or before May 19, 2024.

The Veteran submitted a Fully Developed Claim, VA 21-526EZ submitted a claim on June 3, 2025, following an intent to file on December 2, 2024. Accordingly, as the claim was submitted following the amendment to DC 7336, the new regulations apply. The Board notes the period on appeal before the Board begins on December 2, 2024, the date service connection was granted for the Veteran's hemorrhoids associated with irritable bowel syndrome (IBS).

As of May 19, 2024, the amended version of Diagnostic Code 7336 provided a 10 percent rating 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 assigned for internal or external hemorrhoids with persistent bleeding and anemia; or continuously prolapsed internal hemorrhoids with three or more episodes per year of thrombosis. 38 C.F.R. § 4.114, Diagnostic Code 7336 (effective May 19, 2024).

In March 2025, the Veteran was afforded a VA examination. The Veteran reported current symptoms of hemorrhoids with constipation causing burning in rectum with occasional blood when he wipes. The Veteran reported treating with Preparation H. The examiner noted external hemorrhoids with intermittent bleeding with IBS. The Veteran did not have anorectal/perianal fistula, rectal or anal stricter, impairment of sphincter control, or rectal prolapse. The Veran did have pruritus ani. The examination results showed abnormal external hemorrhoids.

When analyzing the evidence under the amended regulation of Diagnostic Code 7336, effective May 20, 2024, the Veteran's hemorrhoids also do not warrant a compensable rating. His hemorrhoids were not shown or reported to be prolapsed internal hemorrhoids with two or less episodes per year of thrombosis; or external hemorrhoids with three or more episodes per year of thrombosis. The evidence also does not reflect that he has internal or external hemorrhoids with persistent bleeding and anemia; or continuously prolapsed internal hemorrhoids with three or more episodes per year of thrombosis. The Veteran's reported symptoms do not nearly approximate the criteria for a compensable rating under the amended regulations for Diagnostic Code 7336.

In reaching its conclusion, the Board acknowledges the Veteran's belief that his hemorrhoids are more severe than the current rating reflects, however, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. Although the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board finds the persuasive medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive. The Veteran hemorrhoid symptoms do not rise to a level to warrant a compensable rating.

Accordingly, the Board finds that the criteria for a compensable rating for the Veteran's hemorrhoids have not been met under the amended regulations for Diagnostic Code 7336, effective May 19, 2024. See 38 C.F.R. §§ 4.114, Diagnostic Code 7336 (effective May 19, 2024). In denying the increased rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Thus, the claim for a
more persuasive. The Veteran hemorrhoid symptoms do not rise to a level to warrant a compensable rating.

Accordingly, the Board finds that the criteria for a compensable rating for the Veteran's hemorrhoids have not been met under the amended regulations for Diagnostic Code 7336, effective May 19, 2024. See 38 C.F.R. §§ 4.114, Diagnostic Code 7336 (effective May 19, 2024). In denying the increased rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Thus, the claim for a compensable rating for hemorrhoids must be denied.

2. Entitlement to a compensable rating for the Veteran's service-connected left ear hearing loss is denied.

The Veteran seeks a compensable rating for his left ear hearing loss, which is currently rated as 0 percent disabling under 38 C.F.R. § 4.85, DC 6100. The Board notes that only the Veteran's left ear hearing loss is service connected.

As an initial matter, the Board notes that the appeal period before the Board begins on June 8, 2021, the date service connection was granted for the Veteran's Left Ear Hearing Loss.

The Board observes at the outset of its analysis that determinations of hearing loss ratings are complex, highly technical and driven by objective data, and as a result, veterans frequently subjectively perceive their hearing loss to be more severe than their respective VA rating reflects. While the Board sympathizes with veterans sincerely pursuing an increased rating based on the disparity between perception and data, it is, in the end, bound by governing law and regulation.

Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test, together with the average hearing threshold measured by puretone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, DC 6100.

For speech recognition scores to be valid for VA disability rating purposes, an examiner must utilize the Maryland CNC word list in performing the examination. 38 C.F.R. § 4.85(a).

To evaluate the degree of disability from service-connected hearing loss, the schedule establishes eleven auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII.

An exceptional pattern of hearing impairment occurs when the puretone threshold in each of the frequencies of 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more. 38 C.F.R. § 4.86 (a). In those situations, the Roman numeral designation for hearing impairment is determined from either Table VI or Table VIA, whichever results in the higher numeral. Id. Further, when the average puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the Roman numeral designation is determined from either Table VI or Table VIA, whichever results in the higher numeral, and elevated to the next higher numeral. 38 C.F.R. § 4.86 (b).

If impaired hearing is service-connected in only one ear, to determine the percentage evaluation from Table VII, the non-service-connected ear will be assigned a Roman Numeral designation for hearing impairment of I, subject to the provisions of 38 C.F.R. §§ 3.383 and 4.85(f).

The law allows for compensation for hearing loss as if both ears were service-connected if the service-connected hearing loss is at least 10 percent disabling and the non-service-connected hearing loss meets the standard for a hearing loss disability for VA purposes under 38 C.F.R. § 3.385, unless the non-service- connected hearing loss is the result of the Veteran's willful misconduct. 38 C.F.R. § 3.383.

Hearing loss is considered a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385.

In
non-service- connected hearing loss is the result of the Veteran's willful misconduct. 38 C.F.R. § 3.383.

In this case, the basic rule for unilateral hearing loss applies. 38 C.F.R. § 4.85(f). As explained below, the rules for exceptional patterns of hearing impairment, and as if both ears were service connected, do not apply. 38 C.F.R. § 4.86 and 38 C.F.R. § 3.383(a)(3).

In July 2021, the Veteran underwent a VA examination for his left ear hearing loss. The VA examiner diagnosed the Veteran with bilateral sensorineural hearing loss, which is rated based on hearing impairment. See 38 C.F.R. § 4.85, DC 6100. The VA examination included an audiological evaluation. Testing showed puretone thresholds, in decibels, as follows:

Frequency (HZ) 1000 2000 3000 4000 Average

Right Ear Loss (db) 35 30 25 35 31.25

Left Ear Loss (db) 35 35 30 35 33.75

Speech recognition testing using the Maryland CNC word list indicated ability of 96 percent in the right ear and 100 percent in the left ear. Id.

Applying the July 2021 results to Table VI, the findings yield a numeric designation of Level I in the left ear. As indicated above, the non-service-connected right ear will be assigned a Roman Numeral designation of Level I. Entering the resulting numeric designation of Level I for the right ear and Level I for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a noncompensable disability rating under Diagnostic Code 6100.

In February 2022, the Veteran underwent a VA examination for his left ear hearing loss. The VA examination included an audiological evaluation. Testing showed puretone thresholds, in decibels, as follows:

Frequency (HZ) 1000 2000 3000 4000 Average

Right Ear Loss (db) 35 25 25 25 27.50

Left Ear Loss (db) 30 45 55 35 41.25

Speech recognition testing using the Maryland CNC word list indicated ability of 94 percent in the right ear and 96 percent in the left ear. Id.

Applying the February 2022 results to Table VI, the findings yield a numeric designation of Level II in the left ear. As indicated above, the non-service-connected right ear will be assigned a Roman Numeral designation of Level I. Entering the resulting numeric designation of Level I for the right ear and Level I for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a noncompensable disability rating under Diagnostic Code 6100.

In March 2025, the Veteran underwent a VA examination for his left ear hearing loss. The VA examination included an audiological evaluation. Testing showed puretone thresholds, in decibels, as follows:

3. Frequency (HZ) 1000 2000 3000 4000 Average

Right Ear Loss (db) 35 35 30 35 33.75

Left Ear Loss (db) 35 35 30 40 35.0

Speech recognition testing using the Maryland CNC word list indicated ability of 80 percent in the right ear and 90 percent in the left ear. Id.

Applying the March 2025 results to Table VI, the findings yield a numeric designation of Level II in the left ear. As indicated above, the non-service-connected right ear will be assigned a Roman Numeral designation of Level I. Entering the resulting numeric designation of Level I for the right ear and Level II for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a noncompensable disability rating under Diagnostic Code 6100.

The test results did not meet thresholds for an exceptional pattern of hearing impairment under 38 C.F.R. § 4.8. In addition, because the Veteran
the right ear and 90 percent in the left ear. Id.

The test results did not meet thresholds for an exceptional pattern of hearing impairment under 38 C.F.R. § 4.8. In addition, because the Veteran's service-connected left ear hearing loss is not at least 10 percent disabling, compensation cannot be granted for hearing loss as if both ears were service-connected. 38 C.F.R. § 3.383.

The Board considered a private medical consultation report stating that comparative testing of the Veteran's hearing in a quiet room and a room with normal day to day noise indicates 40% hearing loss in the left ear. See January 2025 Report of Examination and Consultation. An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include both a puretone audiometry test and Maryland CNC test. 38 C.F.R. § 4.85(a); Savage v. Shinseki, 24 Vet. App. 259, 263-64 (2011). The private clinician's opinion does not fulfill these rating requirements and therefore has limited probative value.

The Board acknowledges the Veteran's communication challenges posed by his hearing loss. However, the objective audiometric testing evidence directs the outcome here and the Board finds a compensable rating for the Veteran's left hear hearing loss is not warranted.

In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the evidence is persuasively against the claim, this doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The appeal is denied.

3. Entitlement to an initial rating of 10 percent for the Veteran's service-connected pseudofolliculitis barbae (PFB) is granted.

4. Entitlement to a separate rating for the Veteran's facial scars due to pseudofolliculitis barbae is granted effective December 2, 2024.

The Veteran's PFB is rated under Diagnostic Code 7806. Effective August 13, 2018, a new General Rating Formula for the Skin applies to DCs 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824.

As an initial matter, the Board notes that the appeal period before the Board begins on December 2, 2024, the date service connection was granted for the Veteran's pseudofolliculitis barbae (PFB). The Veteran was granted service connection for PFB in a June 3, 2025, rating decision which granted an effective date of December 2, 2024.

Under the General Formula, a noncompensable rating is assigned for 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. 38 C.F.R. § 4.118, General Rating Formula for the Skin.

A 10 percent rating is warranted for at least one of the following: characteristic lesions involving at least 5 percent but less than 20 percent of the entire body affected; at least 5 percent but less than 20 percent of exposed areas affected; 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. Id.

A 30 percent rating is warranted for at least one of the following: characteristic lesions involving 20 to 40 percent of the entire body; 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
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. Id.

A 30 percent rating is warranted for at least one of the following: characteristic lesions involving 20 to 40 percent of the entire body; 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. Id.

A 60 percent rating is warranted for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more; 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. Id.

The General Rating Formula for the Skin also instructs to rate dermatitis under Diagnostic Code 7800 for disfigurement of the head, face, or neck or Diagnostic Codes 7801, 7802, 7803, 7804, or 7805 for scars, if applicable, depending on the predominant disability. Id.

Under the VA regulations amended in August 2018, systemic therapy is defined as treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a).

The Board applies an intentionally generous standard of proof unique in American jurisprudence, created in recognition of the nation's great debt to its veterans. Wise v. Shinseki, 26 Vet. App. 517, 531 (2014). A veteran is given the benefit of the doubt on any material issue, provided there is an "approximate balance of positive and negative evidence." 38 U.S.C. § 5107; 38 C.F.R. § 4.3.

In March 2025 the Veteran underwent a VA skin disease examination. The examiner noted a diagnosis of pseudofolliculitis barbae with current symptoms of raised itchy bumps in beard area when he shaves with no current treatment noted. The Veteran, however, was noted to have been treated with medication both oral and topical in the past 12 months for a skin condition. Total duration of medication use in the past 12 months was marked as constant/near constant. No additional treatments were noted. Total body area exposure was noted to be less than 5 percent. The Veteran's skin condition was also noted in causing scarring.

In June 2025, an addendum to a previous medical examination noted the Veteran used both topical and oral medication for less than 6 weeks in the past 12 months.

The above listed symptomatology is consistent with a 10 percent compensable rating, because the Veteran's PFB impacted less than 5 percent of his total body area and none of his exposed body area, and that his skin disorder required oral and topical therapy. See 38 C.F.R. § 4.118, Diagnostic Code 7813. There is no evidence to support that the characteristic lesions involve 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected to warrant a rating higher than 10 percent.

The Board has also considered whether any other Diagnostic Codes related to skin disabilities would provide for a higher or separate disability evaluation. Here, the evidence reflects that the Veteran's PFB warrants an additional separate service-connected rating under a different diagnostic code, as his PFB is manifested by disfigurement or scarring to warrant a separate rating under Diagnostic Codes. See 38 C.F.R. § 4.118. The March 2025, VA Scars examination specifically noted that the Veteran's PFB had caused scarring. Additionally, the March 2025 VA examination had scars or disfigurement of the head, face, or neck. The scars were noted to not be painful, unstable, or due to burns. The examiner noted roughly 20 pseudofolliculitis scars on anterior neck below mandibular line each measuring 0.3 x 0.3 cm. Accordingly, a separate rating for scarring under Diagnostic Code 7800, for burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck is warranted.

5, VA Scars examination specifically noted that the Veteran's PFB had caused scarring. Additionally, the March 2025 VA examination had scars or disfigurement of the head, face, or neck. The scars were noted to not be painful, unstable, or due to burns. The examiner noted roughly 20 pseudofolliculitis scars on anterior neck below mandibular line each measuring 0.3 x 0.3 cm. Accordingly, a separate rating for scarring under Diagnostic Code 7800, for burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck is warranted.

In conclusion, the evidence of record persuasively weighs for the assignment of a compensable rating of 10 percent for PFB as well as a separate service-connected disability for scarring, secondarily to the Veteran's PFB.

Service connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, to establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may be established on a secondary basis for a disability resulting from a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability results from the service-connected disability. 38 U.S.C. §§ 1110, 1131; Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023) (holding that section 1110 "requires compensation when a service-connected disease or injury is a but-for cause of a present-day disability"). The but-for causation standard in a secondary service-connected case is not limited to a single cause and effect, but rather contemplates multi-causal links, including action and inaction. See Spicer, supra.

5. Entitlement to service connection for pain of left shoulder is granted.

The Veteran seeks entitlement to service connection for left shoulder pain. Specifically, the Veteran contends he injured his left shoulder in service when carrying heavy packs and weapons as a Marine Rifleman. See September 28, 2025, Statement in Support of Claim.

The Board notes a VA examination was not performed; however, the Veteran submitted a private positive nexus opinion from a Florida chiropractor that may examine and diagnose the human living body and its disease by use of any physical, chemical, electrical, or thermal method; use of x ray for diagnosis, phlebotomize, and use any other general method of examination for diagnosis and analysis taught in any school of chiropractor according to Florida state law. The Florida chiropractor opined the Veteran has a diagnosis of left shoulder pain with an onset due to compensatory biomechanical factors during active-duty service and that it is as likely as not the Veteran's left shoulder pain is directly and causally related to elements of his cervical spine condition incurred during military service. The Board accepts a licensed chiropractor who has expertise in mobility and other issues pertaining to joints, including the shoulder.

The January 2025 Report of Examination and Consultation indicate the Veteran has positive Yocum's and Apley's tests leading to a diagnosis of pain of the left shoulder. Notably, regarding the "current disability" element of service connection, "pain need not be diagnosed as connected to a current underlying condition to function as an impairment." Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018). Rather, "[t]o establish the presence of a disability, a veteran will need to show that [their] pain reaches the level of a functional impairment of earning capacity." Id. at 1367-68.

In light of the findings of the January 2025 VA Report of Examination and Consultation, the Board finds the Veteran's left shoulder pain" reaches the level of a functional impairment of earning capacity" so as to constitute a current diagnosis under Saunders. Thus, the first element of service connection is met.

to a current underlying condition to function as an impairment." Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018). Rather, "[t]o establish the presence of a disability, a veteran will need to show that [their] pain reaches the level of a functional impairment of earning capacity." Id. at 1367-68.

The second element is also met. In a September 28, 2025, statement, the Veteran described left shoulder pain beginning during service as a result of lifting heavy gear overhead for duties related to his MOS. The Veteran's service treatment records are silent for diagnosis or treatment.

The Board finds service connection for left shoulder pain is warranted. The Board finds this testimony regarding the onset and continuation of symptoms to be competent and credible. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) ("A lay witness may testify as to his or her observations of the features or symptoms that a claimant exhibited."). Resolving doubt in the Veteran's favor, the Board finds the Veteran's left shoulder pain had its onset in service. See 38 C.F.R. § 3.303(a) ("Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces[.]"); Flynn v. Brown, 6 Vet. App. 500, 503 (1994) (noting "the element of cause and effect has been totally by-passed in favor of a simple temporal relationship between the incurrence of the disability and the period of active duty"). Thus, all three elements necessary to establish direct service connection have been met. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Fountain v. McDonald, 27 Vet. App. 258 (2015). In light of the foregoing, service connection is warranted for left shoulder pain.

6. Entitlement to service connection for low back condition is granted.

7. Entitlement to service connection for right lower extremity radiculopathy, to include as secondary to the Veteran's back condition, is granted.

8. Entitlement to service connection for left lower extremity radiculopathy, to include as secondary to the Veteran's back condition, is granted.

The Veteran seeks entitlement to service connection for low back condition. Specifically, the Veteran contends that he has suffered since fast rope repel training and ruck marching while in service. See January 2025 Report of Examination and Consultation.

The Veteran underwent a VA examination in July 2021. The examiner did not find a diagnosis for low back condition or lower extremity radiculopathy. However, the examiner noted the Veteran reported sharp pain in his mid-back, occasional tingling/numbness that radiates down the front of both legs, spasms, and tingling that radiates down both arms. The Veteran reported the pain starting in his low and mid back after ruck marches when stationed in Hawaii.

The Veteran underwent a VA examination in March 2025. The examiner noted a lumbosacral strain. The examiner also noted mild left lower extremity radiculopathy. There was no right lower extremity radiculopathy noted. The diagnosis of lumbosacral strain meets the first element for service connection, a current diagnosis as it concerns the lower back condition. The examiner did not document the description of history of the Veteran's condition. The Veteran's service treatment records are silent for diagnosis but do note treatment for left lower quadrant back pain relating to nausea with no injury noted. See August 14, 1997, Service Treatment Records.

The Veteran submitted a clinical diagnosis of lumbar spine strain from an advanced practice registered nurse (APRN) dated January 13, 2022. The clinical diagnosis was accompanied by a medical opinion regarding the Veteran's lumbar spine strain condition. The APRN opined that it was at least as likely as not that the Veteran's current lumbar spine strain condition is secondary to, related to, and /or aggravated by his service-connected right achilles tendonitis, right foot, left achilles, tendonitis, left foot with associated compensatory walking strategies with biomechanical and kinematic changes.

The Veteran further submitted a private positive nexus opinion from a Florida chiropractor. The Florida chiropractor noted advanced imaging showing deg
Treatment Records.

The Veteran further submitted a private positive nexus opinion from a Florida chiropractor. The Florida chiropractor noted advanced imaging showing degenerative changes. The examination of the lumbar spine revealed tight and tender fibers of the lumbar paraspinals and quadratus lumborum with muscular guarding upon palpation. There is restriction with loss of normal motion of the L4/L5 and sacroiliac joints. Muscle strength is equal bilaterally. Dermatomes are intact and equal bilaterally. Range of motion values were flexion to 30 degrees: extension to 10 degrees: left lateral bending to 20 degrees; right lateral bending to 15 degrees. Ultimately, the Florida chiropractor opined it is as likely as not that the Veteran's lumbar spine condition is directly and causally related to service. The Florida chiropractor further opined the Veteran had diagnoses of bilateral lower extremity radiculopathies directly and causally related to the Veteran's spine condition and that it is as likely as not that the same is directly and causally related to service.

As with the left shoulder, the Board accepts a licensed chiropractor who has expertise in mobility and other issues pertaining to joints, including the lumbar spine condition and bilateral lower extremity radiculopathies.

The Board finds service connection for low back condition and bilateral lower extremity radiculopathies is warranted. The Board finds the Veteran's contentions regarding the onset and continuation of symptoms to be competent and credible. Resolving doubt in the Veteran's favor, the Board finds the Veteran's low back condition had its onset in service. Thus, all three elements necessary to establish direct service connection have been me for low back condition. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Fountain v. McDonald, 27 Vet. App. 258 (2015). Furthermore, the Board finds the Veteran currently has bilateral lower extremity radiculopathy that is a result of the Veteran's low back condition. Thus, the elements necessary to establish secondary service connection have been met for bilateral lower extremity radiculopathies. Entitlement to direct service connection for low back condition as well as secondary service connection for bilateral lower extremity radiculopathies is granted.

REASONS FOR REMAND

1. Entitlement to service connection for glossopharyngeal nerve damage caused by tonsillectomy is remanded.

The Veteran seeks entitlement to service connection for glossopharyngeal nerve damage caused by tonsillectomy performed during service as well as sleep apnea, and headaches. Specifically, the Veteran contends that his in-service tonsillectomy caused chronic pain, swallowing difficulties, and nerve damage.

The RO favorably found in the June 3, 2025, Rating Decision that the evidence shows a qualifying event, injury, or disease had its onset during the Veteran's service as the Veteran's exit exam dated May 5, 2001, shows airway compromise status post tonsillectomy. Under the AMA the Board is bound by favorable findings made by the AOJ in the absence of evidence of clear and unmistakable error. 38 C.F.R. § 3.104 (c). Additionally, the Veteran has a diagnosis of glossopharyngeal nerve damage caused by tonsillectomy. See Report of Examination and Consultation.

Thus, the first element of service connection, a current diagnosis, has been met. Therefore, the questions that remain are whether the Veteran's condition had an in-service incurrence or aggravation of an injury or disease, and whether a nexus, or link exists, between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

The Veteran provided a November 2021 "Report of Consultation and Examination," authored by a Florida chiropractor, who is licensed in that jurisdiction to "diagnose the human living body and its disease." There is no evidence, however, that the chiropr
the Veteran's condition had an in-service incurrence or aggravation of an injury or disease, and whether a nexus, or link exists, between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

The Veteran provided a November 2021 "Report of Consultation and Examination," authored by a Florida chiropractor, who is licensed in that jurisdiction to "diagnose the human living body and its disease." There is no evidence, however, that the chiropractor has any expertise in the area of glossopharyngeal nerve damage caused by tonsillectomy, and therefore the opinion is of limited probative value. Furthermore, he gave no indication that he reviewed the Veteran's medical records before reaching the provided opinion. Glossopharyngeal nerve damage caused by tonsillectomy is not concerning mobility or other issues pertaining to joints.

In March 2025, a medical opinion disability benefits questionnaire was completed. However, the nurse practitioner only commented, "for the claimed condition in Section II an opinion was not rendered as there was no pathology to render a diagnosis." The Board finds this opinion inadequate. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). It was a pre-decisional duty to assist error to not obtain an adequate VA examination and medical opinion. Remand is required.

2. Entitlement to service connection for sleep apnea is remanded.

The Veteran seeks entitlement to service connection for sleep apnea. Specifically, the Veteran contends that that he was seen by emergency services while in service for dyspnea and shortness of breath which at the time of the incident the medical personnel related the condition to his tonsils. See September 29, 2025, Statement in Support of Claim.

The Veteran submitted a home sleep apnea test interpretation from the Jacksonville Sleep Center. The test interpretation noted a diagnosis of moderate obstructive sleep apnea. Thus, the first element of service connection has been met. Therefore, the questions that remain are whether the Veteran's condition had an in-service incurrence or aggravation of an injury or disease, and whether a nexus, or link exists, between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Here, it does not appear that the Veteran has undergone a VA examination. A medical examination or medical opinion is necessary in a claim for service connection when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-86 (2006). See also 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i).

These elements are satisfied with regard to the claim of service connection for obstructive sleep apnea. Regarding the first element, for purposes of McLendon, the Veteran is considered competent to report symptoms of loud snoring, hypersomnia, witnessed episodes, and weight. Regarding the second element, in his claim form, the Veteran alleges the disorder beginning in service. Regarding the third and fourth elements, there is an indication that obstructive sleep apnea could be related to service, but there is insufficient evidence of record by which the Board can make a decision.

It was a pre-decision
U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i).

It was a pre-decisional duty to assist error to not obtain a VA examination and medical opinion where the McLendon elements are satisfied. Remand is required.

3. Entitlement to service connection for migraine headaches is remanded.

The Veteran seeks entitlement to service connection for migraine headaches. Specifically, the Veteran contends that he has suffered from migraine headaches since 1999 with them progressively worsening throughout his career. See January 2025 Report of Examination and Consultation.

The RO favorably found in the June 3, 2025, Rating Decision that the evidence shows a qualifying event, injury, or disease had its onset during the Veteran's service as the Veteran's service treatment records dated January 26, 1998, shows complaint of headache. Further, the Veteran has been diagnosed with a disability as results from the VA disability Benefits Question on March 25, 2025, shows a current diagnosis of tension headaches. Under the AMA the Board is bound by favorable findings made by the AOJ in the absence of evidence of clear and unmistakable error. 38 C.F.R. § 3.104 (c).

Thus, the first and second element of service connection, a current diagnosis and an in-service incurrence have been met. Therefore, the question that remains is whether a nexus, or link exists, between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

The Veteran underwent a VA examination in March 2025. The examiner noted the condition began in 2015 with head pain. The examiner ultimately opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the medical records do not confirm in service headache condition to establish a nexus. The Board finds this opinion is inadequate. A VA examiner may not generally rely on the absence of evidence as negative evidence. See, e.g. Fountain v. McDonald, 27 Vet. App. 258, 272-75 (2015); Buczynski v. Shinseki, 24 Vet. App. 221, 223-24 (2011); Jones v. Shinseki, 23 Vet. App. 382, 389-90 (2010). Further, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). It was a pre-decisional duty to assist error to not obtain an adequate VA examination and medical opinion. Remand is required.

4. Entitlement to service connection for hypertension is remanded.

The Veteran seeks entitlement to service connection for hypertension. Specifically, the Veteran seeks secondary service connection for hypertension. The Veteran contends that after developing his service-connected right achilles tendonitis, right foot and left achilles tendonitis, let foot that it became painful to exercise. Overtime, the Veteran gained a significant amount of weight and developed high blood pressure. See June 2021, Statement in Support of Claim.

The Veteran provided a November 2021 "Report of Consultation and Examination," authored by a Florida chiropractor, who is licensed in that jurisdiction to "diagnose the human living body and its disease." Again, there is no evidence, however, that the chiropractor has any expertise in the area of hypertension, and therefore the opinion is of limited probative value.
Specifically, the Veteran seeks secondary service connection for hypertension. The Veteran contends that after developing his service-connected right achilles tendonitis, right foot and left achilles tendonitis, let foot that it became painful to exercise. Overtime, the Veteran gained a significant amount of weight and developed high blood pressure. See June 2021, Statement in Support of Claim.

Here, it also does not appear that the Veteran has undergone a VA examination. A medical examination or medical opinion is necessary in a claim for service connection when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-86 (2006). See also 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i).

These elements are satisfied with regard to the claim of service connection for obstructive sleep apnea. Regarding the first element, for purposes of McLendon, the Veteran is considered competent to report symptoms of weight gain, headaches, fatigue, and feeling disoriented. Regarding the second element, in his claim form, the Veteran alleges the disorder due to a service-connected condition. Regarding the third and fourth elements, there is an indication that hypertension could be related to service or a service-connected disability, but there is insufficient evidence of record by which the Board can make a decision.

It was a pre-decisional duty to assist error to not obtain a VA examination and medical opinion where the McLendon elements are satisfied. Remand is required

The matters are REMANDED for the following action:

1. Provide an examination and obtain a medical opinion regarding the nature, onset, and etiology of any glossopharyngeal nerve damage caused by tonsillectomy, sleep apnea, migraine headaches, and hypertension. The examiner should review the entire claims file, conduct all necessary tests and studies, and provide the requested opinions:

(a.) Whether the Veteran's claimed conditions had their onset while the Veteran was in service.

(b.) If "no" to (a.) above, whether the Veteran's claimed conditions were caused by an injury, disease or event that occurred during the Veteran's service.

(c.) If "no" to (b.) above, whether the Veteran's claimed conditions were caused by a service-connected disability. When evaluating this causal relationship, the examiner should apply a "but for" standard-that is, if resolution of the service-connected disability would also resolve the claimed disability, then the service-connected disability is a "but for cause" of the claimed disability. This standard allows for multiple contributory causes, as well as for intermediate causes (e.g., when the claimed disability is caused by medication for or treatment of a service-connected disability).

(d.) If "no" to (c.) above, whether the Veteran's claimed conditions were aggravated (i.e., made more severe) by a service-connected disability. When evaluating this relationship, the examiner should apply the same "but for" standard as for causation in (c.) above-that is, if resolution of the service-connected disability would reduce the severity of the claimed disability, secondary service connection applies.

2. The examiner should also consider the Veteran's reports concerning the onset and recurrence of his symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible?

3. The examiner may NOT rely on the absence of a medical record or evidence of medical treatment as the sole rationale for any negative medical nexus opinion. If the examiner finds the lack of documented treatment in service or post-service to be of medical significance given the relative severity, common symptomatology, and usual treatment of the claimed
reports concerning the onset and recurrence of his symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible?

4. All opinions, findings and conclusions must be supported by a complete rationale, including references to patient history, evidence in the record, medical knowledge, publications, or other sources of information relied on in the examiner's analysis.

5. All opinions, findings and conclusions must consider the benefit-of-the-doubt doctrine, which means the VA must find in favor of the Veteran when positive evidence is at least "approximately balanced" with or "nearly equal" to the negative evidence on any material issue.

Continued next page.

6. If any of the requested opinions or responses cannot be provided without resorting to speculation, the examiner must explain why this is so.

Timothy Cothrel

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board KMMH

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.

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