Case A26041007

CORY M. PICTON · 2026 · Case ID: A26041007

MIXED

Summary

The veteran, who served honorably in the U.S. Navy from August 2012 to August 2016, appeals a rating decision concerning several conditions. The Board granted service connection for left knee patellofemoral pain syndrome with osteoarthritis and limitation of extension, establishing an effective date of January 15, 2020, based on an intent to file. Service connection for bilateral foot disabilities was also granted, with the Board resolving doubt in the veteran's favor, finding the condition related to service despite an initial unfavorable VA opinion that was later supplemented with a favorable one. Service connection for keratoconus was granted, with the Board finding it related to in-service LASIK surgery and resolving doubt in the veteran's favor. The Board also restored a 20 percent rating for hemorrhoids, finding a prior reduction improper due to procedural and substantive errors, specifically the lack of discussion regarding improvement in the veteran's ability to function under ordinary conditions. Several other claims were remanded: low back disability secondary to knee disabilities, bilateral hip disabilities secondary to knee disabilities, GERD prior to August 10, 2022, an increased rating for TMJ disease prior to February 3, 2023, an increased rating for a psychiatric disability prior to December 22, 2021, and TDIU. The remands are primarily due to inadequate VA medical opinions and missing treatment records.

Rationale

Intent to file received January 15, 2020; Completed claim received within one year of intent to file; Established earlier effective date

Service Branch

NAVY

Special Benefit

TDIU

Docket No.

250418-535538

Full Decision Text

Citation Nr: A26041007
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 250418-535538
DATE: April 30, 2026

ORDER

An effective date of January 15, 2020, but no earlier for the grant of service connection for left knee patellofemoral pain syndrome with osteoarthritis, limitation of extension is granted.

Service connection for bilateral foot disabilities is granted.

Service connection for Keratoconus is granted.

The reduction from a 20 percent rating to a noncompensable rating effective September 11, 2023, was improper, and restoration of the 20 percent rating is granted.

REMANDED

Service connection for a low back disability, to include as secondary to service-connected knee disabilities is remanded.

Service connection for bilateral hip disabilities, to include as secondary to service-connected knee disabilities, is remanded.

Service connection for gastroesophageal reflux disease prior to August 10, 2022, is remanded.

An initial rating higher than 10 percent prior to February 3, 2023, for temporomandibular joint disease (TMJ) is remanded.

An increased rating higher than 30 percent prior to December 22, 2021, and in excess of 50 percent thereafter for persistent depressive disorder with anxious distress and bruxism (psychiatric disability), is remanded.

A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded.

FINDINGS OF FACT

1. A complete and proper intent to file for VA benefits was received on January 15, 2020, and a formal claim for service connection for the issue on appeal was received within one year.

2. Resolving doubt in the Veteran's favor, her bilateral foot disabilities began during active service.

3. The competent medical evidence shows that the Veteran's keratoconus is due to service.

4. The evidence does not demonstrate that there was sustained improvement in her hemorrhoids, nor does the evidence demonstrate that there was actual improvement in her ability to function under the ordinary conditions of life and work.

CONCLUSIONS OF LAW

1. The criteria for entitlement to an effective date of January 15, 2020, but no earlier, for the award of service connection for left knee patellofemoral pain syndrome with osteoarthritis, limitation of extension are met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.155, 3.156, 3.400.

2. The criteria for Service connection for bilateral foot disabilities are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

3. The criteria for Service connection for keratoconus are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The reduction in rating for the Veteran's hemorrhoids from 20 percent noncompensable was not proper. 38 U.S.C. §§ 1155, 1159, 5107; 38 C.F.R. §§ 3.105(e), 3.344, 4.1, 4.2, 4.85, Diagnostic Code (DC) 7336.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served honorably in the United States Navy on active duty from August 2012 to August 2016.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2025 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), the agency of original jurisdiction (AOJ).

In the April 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket.

Therefore, the Board may only consider the evidence of record at the time of the April 2025 AOJ decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition
of record at the time of the April 2025 AOJ decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801.

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

However, because the Board is remanding the claims of service connection for a low back disability, bilateral hip disabilities, GERD prior to August 10, 2022, increased ratings for TMJ disease, a psychiatric disability, and a TDIU, 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).

1. An effective date of January 15, 2020, but no earlier for the grant of service connection for left knee patellofemoral pain syndrome with osteoarthritis, limitation of extension

An award of direct service connection will be effective on the day following separation from active military service or the date on which entitlement arose if the claim is received within one year of separation from service. Otherwise, except as specifically provided, the effective date of an evaluation and award for pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400.

Effective March 24, 2015, a change in regulation requires claims be filed on standard forms, eliminating constructive receipt of claims and informal claims. See 38 C.F.R. §§ 3.1 (p), 3.150, 3.155, 3.160(a). Instead of informal claims, the new regulation provides that a claimant may request an application for benefits, upon receipt of which, the Secretary shall notify the claimant of the information necessary to complete the application form or form prescribed by the Secretary. 38 C.F.R. § 3.155(a).

The regulation also allows a claimant to submit an intent to file a claim, and VA may recognize the receipt date of the intent to file a claim as the date of claim so long as VA receives the successfully completed claim form within a year. 38 C.F.R. § 3.155(b). There are three ways in which a claimant may submit an intent to file a claim: (i) saved electronic application when an application otherwise meeting the requirements of paragraph (b) is electronically initiated and saved in a claims submission tool with a VA web-based electronic claims application system, (ii) written intent, signed and dated on the intent to file a claim form prescribed by the Secretary, and (iii) oral intent communicated to designated VA personnel, recorded in writing, and documented in the claimant's records. Id.

Records indicate that VA received the Veteran's intent to file on January 15, 2020. On May 18, 2020, a fully developed claim was received from the Veteran for service connection for left knee patellofemoral pain syndrome, among other issues. A completed application form, appropriate to the benefit sought, was received within one year of receipt of the intent to file a claim. Therefore, the date the intent to file a claim was received is considered the date of the completed claim, and an earlier effective date of January 15, 2020, is granted. Id.

Service connection

Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

To establish service connection for a disability there must be competent
Service connection

To establish service connection for a disability there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)).

2. Service connection for bilateral foot disabilities is granted.

The Veteran contends that her bilateral foot disabilities began in service. Specifically, she contends that her job in the Navy required long periods of standing on metal floors without stress mats and that her feet constantly hurt despite wearing inserts in her boots. See August 2021 VA 21-526EZ, Fully Developed Claim.

Initially, the Board acknowledges that the AOJ made the following favorable findings in the May 2023 rating decision: the Veteran has been diagnosed with plantar fasciitis and service treatment records (STRs) show that she reported pain in her arches on her July 2016 separation medical examination. The Board will not disturb these favorable findings and finds that the first two elements of service connection are met.

Turning to the other elements, the Veteran's entrance examination in November 2011 does not document any foot issues. The Veteran is therefore considered sound on entrance into military service. See 38 U.S.C. § 1111.

Accordingly, the question before the Board is whether the Veteran's currently diagnosed bilateral foot disabilities had their onset during or is otherwise related to service.

After review of the evidence and resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for bilateral foot disabilities is warranted.

VA obtained an examination and opinion in February 2018. The examiner diagnosed the Veteran with bilateral plantar fasciitis. The Veteran reported the onset of her foot pain in her arches during service that continued since. See February 2018 VA Medical Opinion Disability Benefits Questionnaire. The examiner opined that the Veteran's foot disabilities are less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The Examiner reasoned that the Veteran was not formally diagnosed with plantar fasciitis until after service despite her complaints at separation. See Id.

VA obtained an addendum opinion in October 2022 in which the examiner opined that the after reviewing the lay statements and service treatment records (STRs), the condition was in-service with confirming documentation. See October 2022 Addendum Report.

In a May 2022 statement, the Veteran's husband reported that they both served as machinery repairmen under the engineering division and that the Veteran complained about foot pain from standing on metal floors. See May 2022 Buddy/Lay Statement.

Ultimately, the Board finds that the Veteran has a current diagnosis of bilateral plantar fasciitis and has competently and credibly reported that her symptoms began during and continued after her service. The Board has no reason to doubt the credibility of these statements. See Layno v. Brown, 6 Vet. App. 465, 470-471 (1994); Jandreau v. Nicholson, 492 F.3d, 1377 (Fed. Cir. 2007). Furthermore, the medical evidence of record, to include a later diagnosis of plantar fasciitis, support the Veteran's assertions. Her assertions are also consistent with the October 2022 VA contract examiner's findings and opinion. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009).

In sum, the evidence supports the finding that the Veteran's bilateral foot disabilities are related to military service. The Board therefore grants the Veteran's claim of service connection for bilateral foot disabilities. See 38 C.F.R. §
471 (1994); Jandreau v. Nicholson, 492 F.3d, 1377 (Fed. Cir. 2007). Furthermore, the medical evidence of record, to include a later diagnosis of plantar fasciitis, support the Veteran's assertions. Her assertions are also consistent with the October 2022 VA contract examiner's findings and opinion. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009).

In sum, the evidence supports the finding that the Veteran's bilateral foot disabilities are related to military service. The Board therefore grants the Veteran's claim of service connection for bilateral foot disabilities. See 38 C.F.R. § 3.303. In so reaching that conclusion, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

3. Service connection for keratoconus is granted.

The Veteran contends that her keratoconus began in service. Specifically, she contends that she underwent Lasik surgery in service that caused her keratoconus. See April 2020 VA 21-526EZ, Fully Developed Claim.

Initially, the Board acknowledges that the AOJ made the following favorable findings in the May 2023 rating decision: the Veteran has been diagnosed with bilateral keratoconus and service treatment records (STRs) show that she underwent Lasik surgery in July 2015. The Board will not disturb these favorable findings and finds that the first two elements of service connection are met.

Turning to the other elements, the Veteran's entrance examination in November 2011 does not document any vision issues. The Veteran is therefore considered sound on entrance into military service. See 38 U.S.C. § 1111.

Accordingly, the question before the Board is whether the Veteran's currently diagnosed keratoconus disability had its onset during or is otherwise related to service.

After review of the evidence and resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for bilateral foot disabilities is warranted.

VA obtained an examination and opinion in October 2020. The examiner diagnosed the Veteran with keratoconus. The Veteran reported the onset of her disability during service that continued since. The examiner opined that her keratoconus was at least as likely as not caused by the in-service injury, event, or illness. The examiner reasoned that the Veteran's keratoconus was caused by her Lasik surgery in service, because Lasik causes corneal thinning that makes keratoconus more likely. See October 2020 VA Medical Opinion Disability Benefits Questionnaire

Ultimately, the Board finds that the Veteran has a current diagnosis of bilateral keratoconus and has competently and credibly reported that her symptoms began during and continued after her service. The Board has no reason to doubt the credibility of these statements. See Layno, 6 Vet. App. 465, 470-471; Jandreau, 492 F.3d, 1377. Furthermore, the medical evidence of record, to include the October 2020 VA examination, support the Veteran's assertions. Davidson, 581 F.3d 1313, 1316.

In sum, the evidence supports the finding that the Veteran's bilateral keratoconus is related to military service. The Board therefore grants the Veteran's claim of service connection for keratoconus. See 38 C.F.R. § 3.303. In so reaching that conclusion, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

4. The reduction from a 20 percent rating to a noncompensable rating effective September 11, 2023, was improper and restoration of the 20 percent rating is warranted.

The Veteran contends that the reduction of her disability evaluation for hemorrhoids was improper as her condition has not improved. See February 2025 VA Form 20-0996 Request for Higher Level Review.

The regulations pertaining to the reduction of disability evaluations contain their own notification and due process requirements. Pursuant to 38 C.F.R. § 3.105(e), where a reduction in the evaluation of a service-connected disability is warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefore and will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level. The veteran is also to be informed that he or she may request a predetermination hearing, provided that the request is received by VA within 30 days from the date of the notice. If no additional evidence is received within the 60-day period and no hearing is requested, final rating action will be taken, and the award will be reduced or discontinued effective the last day of the month in which the 60-day period from the date of notice to the veteran expires. 38 C.F.R. § 3.105(e).

In this case, a January 2024 rating decision proposed to reduce the hemorrhoid evaluation from 20 percent to noncompensable. A January 2024 letter notified the Veteran of the proposed rating reduction and informed the Veteran of her right to challenge the proposed reduction and her right to request a hearing within 30 days of the letter. The May 2024 rating decision reduced the Veteran's hemorrhoids from 20 percent to noncompensable, effective September 11, 2023. Therefore, the Board finds that the procedural requirements for the reduction were satisfied. 38 C.F.R. § 3.105(e). Thus, the analysis proceeds to whether the reduction was factually warranted.

Moving to the substantive requirements of a rating reduction, Congress has provided that a veteran's disability rating will not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C. § 1155. For reductions in rating to be properly accomplished, specific requirements must be met. See 38 C.F.R. § 3.344; see also Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992). The Court of Appeals for Veterans Claims (Court) has discussed principles applicable in all rating reduction cases, regardless of the rating level or the length of time that the rating has been in effect. Specifically, the Court held that in order to effectuate a rating reduction, VA must ascertain: (1) whether, based upon a review of the entire recorded history of the condition, the evidence reflects an actual change in the disability; (2) whether the examination reports reflecting such change are based upon thorough examinations; and (3) whether any improvement in the disability actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. See 38 C.F.R. § 3.344(a); Brown v. Brown, 5 Vet. App. 413, 421 (1993); Kitchens v. Brown, 7 Vet. App. 320 (1995); see also Hedgepeth v. Wilkie, 30 Vet. App. 318, 323-24 (2018).

Where a disability rating has been in effect less than 5 years, a rating reduction is warranted where reexamination of the disability discloses improvement of that disability. See 38 C.F.R. § 3.344(c). For ratings in effect for 5 years or more, there are other specific requirements that must be met. See 38 C.F.R. § 3.344(a), (b). 38 C.F.R. § 3.344(a) provides that VA examinations that are less full and complete than those on which the payments were authorized or continued will not be used as a basis of reduction. Further, under 38 C.F.R. § 3.344(a), even if material improvement is clearly reflected in the record, VA is to consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. The Court of Appeals for Veterans Claims (Court) has consistently held that when a disability rating is reduced without following the applicable regulations, the reduction is void ab initio. See Greyzck v. West, 12 Vet. App. 288, 292 (1999).

Lastly, the Court has also held that though a rating reduction may have been supported by the evidence on file at the time of the reduction, the Board must consider pertinent post-reduction evidence favorable to restoring the rating. See Dofflemeyer, supra.

In this case,
344(a), even if material improvement is clearly reflected in the record, VA is to consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. The Court of Appeals for Veterans Claims (Court) has consistently held that when a disability rating is reduced without following the applicable regulations, the reduction is void ab initio. See Greyzck v. West, 12 Vet. App. 288, 292 (1999).

In this case, although the AOJ found that the Veteran's symptoms had improved, there was no discussion regarding her functioning under the ordinary conditions of life and work. The AOJ likewise did not provide any rationale or discussion regarding improvement in the ordinary conditions of life and work in any subsequent adjudicatory documents. The Board notes, therefore, that it is unable to assess whether there was actual improvement in the ordinary conditions of life because the AOJ failed to make the appropriate findings. The Board finds that the May 2024 rating reduction for the Veteran's hemorrhoids was improper and is therefore void ab initio. Accordingly, the previously assigned 20 percent rating for the Veteran's service-connected hemorrhoids is restored. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991) (when a rating reduction is made that does not comply with the law, the prior rating must be restored).

REASONS FOR REMAND

1. Service connection for a low back disability, to include as secondary to service-connected knee disabilities is remanded.

The Veteran contends that her low back disability is related to service. Specifically, she argues that her low back disability is caused by her altered gait due to her service-connected knee disabilities.

Prior to the rating decision on appeal, the evidence of record indicated another VA examination was warranted.

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). A medical opinion is considered adequate "where it is based on consideration of the Veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). If an examination report does not contain sufficient detail, "it is incumbent upon the rating board to return the report as inadequate for evaluation purposes." 38 C.F.R. § 4.2; see Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report).

The Veteran attended a VA examination for her low back disability in May 2023. Regarding secondary service connection, the examiner opined that the Veteran's low back disability is less likely than not proximately due to or the result of the Veteran's service-connected knee disabilities. The examiner reasoned that knee disabilities do not directly cause lumbosacral strain and there is not a direct relationship between the two. See May 2023 Medical Opinion Disability Benefits Questionnaire.

The Board finds that the May 2023 VA opinion did not provide an adequate rationale and instead provided vague and conclusory statements based on a lack of evidence. Medical opinions that contain only conclusions and do not provide an etiological opinion or provide unsupported conclusions are inadequate. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

Additionally, the May 2023 secondary service-connection opinion failed to address aggravation. See El-Amin v. Shinseki, 26. Vet. App. 136, 138 (2013) (In secondary service connection claims, a medical opinion is inadequate if it does not address both causation and aggravation of the nonservice-connected condition). In the context of secondary service connection, aggravation means "any increase in disability." Allen v. Brown, 7 Vet. App. 439, 448 (1995); Ward v. Wilkie, 31 Vet. App. 233 (2019); 38 C.F.R. § 3.310.

As such, the Board finds that a remand is necessary to correct these pre-decisional duty to assist errors.

2. Service connection for bilateral hip disabilities, to include as secondary to service-connected knee disabilities, is remanded.

The Veteran asserts that her bilateral hip disabilities are due to service, to include as secondary to her service-connected knee disabilities.
causation and aggravation of the nonservice-connected condition). In the context of secondary service connection, aggravation means "any increase in disability." Allen v. Brown, 7 Vet. App. 439, 448 (1995); Ward v. Wilkie, 31 Vet. App. 233 (2019); 38 C.F.R. § 3.310.

As such, the Board finds that a remand is necessary to correct these pre-decisional duty to assist errors.

2. Service connection for bilateral hip disabilities, to include as secondary to service-connected knee disabilities, is remanded.

The Veteran asserts that her bilateral hip disabilities are due to service, to include as secondary to her service-connected knee disabilities.

VA obtained a medical examination and opinion in December 2022 for the Veteran's hips. The examiner opined that the Veteran's diagnosed hip disabilities are less likely than not related to military service. The examiner reasoned that there was no diagnosed hip disability in service. See January 2023 Medical Opinion Disability Benefits Questionnaire.

Upon review, the Board finds the current VA opinion insufficient for the purposes of determining entitlement to service connection, and thus, the AOJ's reliance on such constitutes a pre-decisional duty to assist error. Specifically, the Board finds that the examiner relied on the absence of documentation in service and did not consider the Veteran's complaints of symptoms since service, or her statements that her symptoms began during service. The examiner has not explained why the lack of medical documentation during service precludes the conclusion that the Veteran's vertigo has any relation to service. For example, the medical examiner has not addressed whether he would expect the Veteran to have sought and received treatment in service. Nor has he explained why the Veteran's lay statements are not medically supported or are otherwise outweighed by medical evidence, or lack thereof, in the record. These deficiencies render the opinion inadequate. See Horn, 25 Vet. App. at 231, 240 (holding that "an unexplained conclusory opinion is entitled to no weight in a service-connection context"); Stefl, 21 Vet. App. 120, 124 (stating that the Board may not assess the probative value of "a mere conclusion by a medical doctor"); Nieves, 22 Vet. App. at 301 (holding an examiner may not merely list facts and conclusions with no reasoned explanation connecting the two).

As the January 2023VA medical opinion is inadequate, a remand is necessary to obtain an adequate opinion and correct this pre-decisional duty to assist error.

3. Service connection for gastroesophageal reflux disease prior to August 10, 2022, is remanded.

Although the July 2024 AOJ rating decision granted service connection for GERD from August 10, 2022, the period prior to that remains on appeal.

The Veteran underwent a VA examination in May 2024 where the Veteran reported that her GERD began during service in 2013 and that her symptoms have worsened over the years. The Board notes that the VA examiner did not provide a nexus opinion as to direct service connection.

Based on the foregoing evidence, a VA examination should have been obtained at the time of the April 2025 rating decision to determine whether her GERD was directly related to her conceded toxic exposure in Southwest Asia. Thus, a remand is warranted to obtain a VA medical opinion for direct service connection. This determination is necessary because if service connection is warranted on a direct basis, an effective date earlier than August 10, 2022 (the earliest effective date for a grant of service connection under the PACT Act) may be warranted.

4. An initial rating higher than 10 percent prior to February 3, 2023, for temporomandibular joint disease (TMJ) is remanded.

The Board notes that in her April 2025 10182, the Veteran's representative asserted he was seeking entitlement to an earlier effective date for the increased 20 percent rating assigned for TMJ disease. The Board notes that a January 2024 rating decision assigned a 20 percent rating for TMJ disease effective February 3, 2023.Therefore, the Veteran's claim was certified to the Board as a claim for an earlier effective date for the 20 percent rating for TMJ. However, the Board notes that the Veteran is in fact attempting to receive a higher staged rating of 20 percent for the appeal period prior to February 3, 2023, for TMJ. Accordingly, the Board has recharacterized the claim on appeal to reflect the Veteran's contentions more accurately. As such increased staged rating claim encompasses an earlier effective date claim, there is no prejudice to the Veteran.

A remand is warranted to ensure the Board's duty to assist is satisfied as to obtaining VA medical records and records of treatment at non-
disease effective February 3, 2023.Therefore, the Veteran's claim was certified to the Board as a claim for an earlier effective date for the 20 percent rating for TMJ. However, the Board notes that the Veteran is in fact attempting to receive a higher staged rating of 20 percent for the appeal period prior to February 3, 2023, for TMJ. Accordingly, the Board has recharacterized the claim on appeal to reflect the Veteran's contentions more accurately. As such increased staged rating claim encompasses an earlier effective date claim, there is no prejudice to the Veteran.

A remand is warranted to ensure the Board's duty to assist is satisfied as to obtaining VA medical records and records of treatment at non-VA facilities authorized by VA. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(3). Specifically, review of the record shows that the Veteran received medical treatment with a Community Care non-VA provider. See June 2022 CAPRI record, page 6.

As such, a remand is required to obtain the missing treatment records. 38 C.F.R. § 3.159(c)(3).

5. An increased rating higher than 30 percent prior to December 22, 2021, and in excess of 50 percent thereafter for the Veteran's service-connected psychiatric disability is remanded.

A remand is warranted to ensure the Board's duty to assist is satisfied as to obtaining VA medical records and records of treatment at non-VA facilities authorized by VA. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(3). Specifically, review of the record shows that the Veteran received mental health treatment with a Community Care non-VA provider. See March 2023 CAPRI record, page 22.

As such, a remand is required to obtain the missing treatment records. 38 C.F.R. § 3.159(c)(3).

6. A total disability rating based on individual unemployability (TDIU) is remanded.

The issue of entitlement to a TDIU is inextricably intertwined with the increased rating claims currently on appeal. Therefore, consideration of entitlement to TDIU must be deferred until the intertwined issue is resolved. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991).

The matters are REMANDED for the following action:

1. Obtain and associate with the Veteran's claims file all outstanding VA and VA authorized non-VA treatment records. Any negative search, to include responses received, should be noted in the record, and communicated to the Veteran. Additionally, in the event records are not obtained, if it is determined that additional search requests would be futile, then a memorandum of unavailability should be drafted and added to the record.

2. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran's low back disability. The claims file and a copy of this remand should be reviewed by the clinician. It is up to the discretion of the reviewing clinician as to whether a new examination is necessary to provide an adequate opinion as to the following:

(a.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's low back disability began in service, within one year of discharge therefrom, or is otherwise the result of military service, to include standing for prolonged periods on steel floors.

(b.) If not found directly related to service, whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's low back disability is caused by the Veteran's service-connected knee disabilities, to include any altered gait caused by such.

Note: For secondary service connection it is enough to show that "but for" the service-connected disability the incremental-increase in severity of a nonservice-connected disease or injury would not have occurred. Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023).

(c.) If not found to be secondarily caused by any of the above, whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's low back disability is aggravated by the Veteran's service-connected knee disabilities.

Note: in addressing (b) and (c) above, the examiner is reminded that separate and distinct opinions with their own supporting rationales should be provided. Additionally, the examiner must address the Veteran's lay statements regarding onset of symptomatology

3. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran's bilateral hip disabilities. The claims file and a copy of this remand should
Cir. 2023).

3. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran's bilateral hip disabilities. The claims file and a copy of this remand should be reviewed by the clinician. It is up to the discretion of the reviewing clinician as to whether a new examination is necessary to provide an adequate opinion as to the following:

(a.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's bilateral hip disabilities began in service, within one year of discharge therefrom, or is otherwise the result of military service, to include standing for prolonged periods on steel floors.

(b.) If not found directly related to service, whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's hip disabilities are caused by the Veteran's service-connected knee disabilities, to include any altered gait caused by such.

(c.) If not found to be secondarily caused by any of the above, whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran'ship disabilities are aggravated by the Veteran's service-connected knee disabilities.

4. Obtain an opinion from an appropriate clinician on the etiology of the Veteran's service-connected GERD. If an examination is deemed necessary to respond to the questions posed, one should be scheduled. The clinician is asked to address the following after reviewing the claims file:

5. For the diagnosed GERD disability, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to an in-service event, injury, or disease, to include in-service exposure to environmental hazards on a direct basis, regardless of any presumption?

A complete and detailed rationale should be provided for every opinion requested by the examiner.

Cory M. Picton

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board McNew, Mia B.

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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