An effective date of February 24, 2019, and no earlier, for the grant of service connection for posttraumatic stress disorder (PTSD), is granted.
Dr. Craig Bash has done thousands of case evaluations at the VA Hospital/regional office/BVA and court levels.
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Citation Nr: A21005299 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 200317-71933 DATE: March 9, 2021 ORDER An effective date of February 24, 2019, and no earlier, for the grant of service connection for posttraumatic stress disorder (PTSD), is granted. Service connection for bilateral dry eye syndrome, status post photorefractive keratectomy (PRK) surgery, is granted. A disability rating in excess of 10 percent for service-connected decreased insulin level with history of reactive hypoglycemia (hypoglycemia), prior to November 8, 2018, is denied. A disability rating of 20 percent, but no higher, for service-connected hypoglycemia, for the period beginning November 8, 2018, is granted. REMANDED The claim of entitlement to service connection for a right foot disorder, to include as secondary to service-connected left foot plantar fasciitis with calcaneal spur (left foot disorder), is remanded. FINDINGS OF FACT 1. On February 24, 2019, VA received the Veteran’s claim to readjudicate a previously denied claim of entitlement to service connection for PTSD on an incorrect application form, but subsequently received the correct form on October 25, 2019. 2. The evidence is at least in equipoise as to whether it was factually ascertainable that the Veteran had PTSD on February 24, 2019. 3. The evidence is at least in equipoise as to whether the Veteran has a current diagnosis of bilateral dry eye syndrome which has been related to her in-service PRK surgery. 4. For the period prior November 8, 2018, the preponderance of the evidence is against a finding that the Veteran’s service-connected hypoglycemia required restricted diet and daily injection of insulin or oral hypoglycemic agent. 5. For the period beginning November 8, 2018, the evidence is at least in equipoise as to whether the Veteran’s service-connected hypoglycemia required restricted diet and oral hypoglycemic agent; however, the preponderance of the evidence is against finding restricted diet, oral hypoglycemic agent, and daily injection of insulin were required. CONCLUSIONS OF LAW 1. The criteria for an effective date of February 24, 2019, for the award of service connection for PTSD, have been met. 38 U.S.C. §§ 5101, 5107; 38 C.F.R. §§ 3.151, 3.155, 3.400. 2. The criteria for service connection for bilateral dry eye syndrome, status post PRK surgery, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for a disability rating in excess of 10 percent for service-connected hypoglycemia, for the period prior to November 8, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.119, Diagnostic Code (DC) 7913. 4. Resolving all reasonable doubt in the Veteran’s favor, the criteria for a disability rating of 20 percent, but no higher, for the period beginning November 8, 2018, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.119, DC 7913. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United Stated Air Force from July 1998 to December 2004, August 2006 to January 2007, July 2009 to October 2009, and November 2009 to May 2010. These matters come before the Board of Veterans’ Appeals on appeal from two rating decisions, dated March 2019 and December 2019, issued by a Department of Veterans Affairs (VA) Regional Office. Specifically, the March 2019 rating decision, in part, denied service connection for a right foot disorder and bilateral dry eye syndrome status-post PRK surgery and continued a 10 percent disability rating for hypoglycemia. The December 2019 rating decision granted service connection for PTSD, assigning a 10 percent disability rating effective October 25, 2019. In a March 2020 VA Form 10182, the Veteran requested review of the rating decisions under the direct review docket. Under direct review, a Board decision is based on the evidence at the time of the prior decision. The Board cannot hold a hearing or accept additional evidence into the record in its direct review. 38 C.F.R. § 20.301. Accordingly, with respect to the Veteran’s claims of entitlement to service connection for bilateral chronic dry eye syndrome, service connection for a right foot disorder, and a rating in excess of 10 percent for hypoglycemia, the Board may only consider the evidence of record as of March 28, 2019, the date of the prior decision from which such claims arise. With respect to the Veteran’s claim of entitlement to an effective date earlier than October 25, 2019 for the award of service connection for PTSD, the Board may only consider the evidence of record as of December 3, 2019, the date of the prior decision from which the claim arises. Earlier Effective Date In general, the effective date of an award of disability compensation, in conjunction with a grant of entitlement to service connection, shall be the later of the day following separation from active service or the date entitlement arose if the claim is received within one year of separation from service; otherwise, the effective date shall be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(b)(2). Additionally, a claim which has been denied in an unappealed Board decision or an unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). However, when a Veteran submits a claim to reopen a previously denied claim, and such claim is subsequently reopened and allowed, absent a claim of a clear and unmistakable error (CUE) in a prior final decision, and a showing thereof, the effective date of the award of disability compensation shall be the date of receipt of the claim to reopen or the date entitlement arose, whichever is later. See 38 C.F.R. § 3.400(r); Leonard v. Nicholson, 405 F. 3d 1333, 1337 (Fed. Cir. 2005). Further, when a Veteran submits an intent to file a claim, or an incomplete application indicating a belief in entitlement to benefits, and a complete claim is filed within one year of the receipt of the intent to file or incomplete application, VA will consider the complete claim as filed as of the date of receipt of such intent to file or incomplete application. 38 C.F.R. § 3.155(b), (c). 1. An effective date of February 24, 2019, and no earlier, for the grant of service connection for PTSD is granted. Factual and Procedural Background. The Veteran’s claim of entitlement to service connection for PTSD was initially denied in a May 2014 rating decision. The Veteran did not appeal the May 2014 rating decision, and accordingly that decision became final. 38 C.F.R. § 20.1103. In a February 2019 VA Form 21-526EZ, the Veteran attempted to reopen her previously denied claim of entitlement to service connection for PTSD. In June 2019, the Veteran was informed that, as her claim of entitlement to service connection for PTSD had previously been denied, VA regulations require that she submit her claim on VA Form 20-0995. See June 2019 VA Correspondence. In an October 2019 VA Form 20-0995, the Veteran submitted a supplemental claim seeking service connection for PTSD. In a December 2019 rating decision, service connection for PTSD was granted, effective October 25, 2019, the date of receipt of the Veteran’s VA Form 20-0995. Thereafter, the Veteran submitted a VA Form 10182, appealing, inter alia, the effective date of the award of service connection for PTSD. This is the matter currently before the Board. The Veteran’s medical records indicate that she possessed a diagnosis of PTSD as early as September 2014. See M.A.F. records, received April 2019. Analysis. The Veteran is seeking an effective date prior to October 25, 2019, for the award of service connection for PTSD. As discussed, when a Veteran submits a claim to reopen a previously denied claim, and such claim is subsequently reopened and allowed, absent a claim of a clear and unmistakable error (CUE) in a prior final decision, and a showing thereof, the effective date of the award of disability compensation shall be the date of receipt of the claim to reopen or the date entitlement arose, whichever is later. See 38 C.F.R. § 3.400(r); Leonard v. Nicholson, 405 F. 3d 1333, 1337 (Fed. Cir. 2005). Additionally, when a Veteran submits an intent to file a claim, or an incomplete application indicating a belief in entitlement to benefits, and a complete claim is filed within one year of the receipt of the intent to file or incomplete application, VA will consider the complete claim as filed as of the date of receipt of such intent to file or incomplete application. 38 C.F.R. § 3.155(b), (c). Here, as discussed above, in the December 2019 rating decision granting service connection for PTSD, the Agency of Original Jurisdiction (AOJ) assigned an effective date of October 25, 2019, identifying this as the date of receipt of the claim to reopen. However, the claim received on February 24, 2019, on an incorrect form may be treated as an incomplete application. As the Veteran filed the complete VA Form 20-0995 within one year of receipt of the February 2019 claim, the Board shall consider such form as having been received on February 24, 2019, the date of receipt of the incomplete application. As such, this date is the appropriate effective date. See 38 C.F.R. § 3.155(c). The acknowledges that the Veteran’s medical records indicate that she was diagnosed with PTSD as early as September 2014. See M.A.F. records. However, an effective date cannot be assigned any earlier than the application from which the grant stemmed from. See Stowers v. Shinseki, 26 Vet. App. 550, 553-54 (2014) (quoting Lalonde v. West, 12 Vet. App. 377, 382 (1999)). Therefore, an effective date of February 24, 2019, but no earlier, for the grant of service connection for PTSD is granted, where it is based on the date of receipt of an intent to file. See 38 C.F.R. § 3.155(b), 3.400(r). Service Connection Service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). However, pursuant to 38 C.F.R. § 3.306(b)(1), the usual effect of medical and surgical treatment in service, having the effect of ameliorating a disease or other conditions incurred before enlistment, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 2. Service connection for bilateral dry eye syndrome, status post PRK surgery, is granted. Factual and Procedural Background. In February 2018, the Veteran filed a claim of entitlement to service connection for bilateral dry eye syndrome. See February 2018 VA Form 21-526EZ. In an April 2018 rating decision, the Veteran’s claim was denied. Thereafter, the Veteran timely filed a Notice of Disagreement (NOD) in May 2018. In February 2019, prior to the issuance of a Statement of the Case (SOC), the Veteran opted into the Rapid Appeals Modernization Program (RAMP), seeking higher-level review. In a March 2019 RAMP rating decision, the AOJ again denied the Veteran’s claim. The Board is bound by the favorable findings that the Veteran has a current diagnosis of dry eye syndrome and that such disorder had its onset during service. See 38 C.F.R. § 20.801(a). Thereafter, the Veteran submitted a VA Form 10182, appealing the denial of entitlement to service connection for bilateral dry eye syndrome. This is the matter currently before the Board. The Veteran’s service treatment records (STRs) indicate that the Veteran underwent PRK surgery in April 2004 and reported experiencing bilateral dry eyes as early as 10 days thereafter. See STR-Medical. The Veteran’s VA treatment records indicate that she has reported increasing eye dryness and uses cyclosporine for treatment of her chronic bilateral dry eye syndrome. See West Los Angeles VA Medical Center (VAMC) records, received November 2018 in CAPRI. In March 2018, the Veteran underwent a VA eye examination in which the examiner opined that the Veteran’s dry eye syndrome was at least as likely as not caused by her in-service PRK surgery. In support of this opinion, the examiner noted that PRK surgery commonly causes dry eye syndrome. See March 2018 VA Eye Conditions Disability Benefits Questionnaire (DBQ); March 2018 VA Medical Opinion DBQ. In May 2018, the Veteran submitted a private opinion, in which the physician opined that the Veteran’s chronic dry eye syndrome is not an expected outcome of PRK surgery. In support of this opinion, while acknowledging that dry eyes are a known complication of PRK surgery, the physician noted that such complication typically returns to baseline at one year following surgery. See May 2018 Private Opinion. The physician also provided a 2012 study which found that, while PRK causes an increase in dry eye symptoms over baseline in the early postoperative period, such symptoms typically return to baseline by one year post-operation. See Yohko Murakami, MD & Edward E. Manche, MD, Prospective, Randomized Comparison of Self-Reported Postoperative Dry Eye and Visual Fluctuation in LASIK and Photorefractive Keratectomy, 119 J. Ophthalmology 2220-2224 (2012). Analysis. The Veteran seeks service connection for her chronic bilateral dry eye syndrome. As noted above, service connection requires evidence of a current disability, an in-service incurrence or aggravation of a disease or injury, and a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, supra. However, pursuant to 38 C.F.R. § 3.306(b)(1), the usual effect of medical and surgical treatment in service, having the effect of ameliorating a disease or other conditions incurred before enlistment, will not be considered service connected unless the disease or injury is otherwise aggravated by service. Here, as discussed above, the Board is bound by the March 2019 RAMP rating decision’s favorable findings that the Veteran has a current diagnosis of dry eye syndrome and that such disorder had its onset during service. See 38 C.F.R. § 20.801(a). As such, this matter turns on whether or not the Veteran’s chronic bilateral dry eye syndrome is considered a usual effect of PRK surgery. As discussed above, in opining that the Veteran’s chronic dry syndrome was at least as likely as noted caused by her in-service PRK surgery, the March 2018 VA examiner noted that PRK surgery commonly causes dry eye syndrome. See March 2018 VA Medical Opinion DBQ. This indicates that dry eye syndrome is a usual effect of PRK surgery. On the other hand, while acknowledging that dry eyes are a known complication of PRK surgery, the May 2018 private physician noted that such complication typically returns to baseline at one year following surgery. See May 2018 Private Opinion. Additionally, the private physician provided a 2012 study which found that, while PRK causes an increase in dry eye symptoms over baseline in the early postoperative period, such symptoms typically return to baseline by one year post-operation. See Yohko Murakami, MD & Edward E. Manche, MD, Prospective, Randomized Comparison of Self-Reported Postoperative Dry Eye and Visual Fluctuation in LASIK and Photorefractive Keratectomy, 119 J. Ophthalmology 2220-2224 (2012). This indicates that the Veteran’s chronic bilateral dry eye syndrome is not a usual effect of PRK surgery. Additionally, though not dispositive, the Board notes that the consent form signed by the Veteran prior to her PRK surgery is silent with respect to dry eye syndrome. See STR-Medical. Based on the above, the Board finds the evidence of record overall supports the finding that the Veteran’s chronic bilateral dry eye syndrome is related to her in-service PRK surgery. Additionally, the Board finds the evidence of record overall supports, at least to an evidentiary position of equipoise, that such disorder is not a usual effect of PRK surgery, and therefore 38 C.F.R. § 3.306(b)(1) is not for application. Accordingly, the Board resolves all reasonable doubt in the Veteran’s favor and finds service connection is warranted. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the assignment of staged ratings may be warranted where the evidence contains factual findings that demonstrate a change in the severity of symptoms during the course of the appeal period. See Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating 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. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. §§ 3.102, 4.3. When a claimant’s disability is not specifically listed in the DC, it is rated analogous to a disability in which the functions affected, as well as the anatomical localization and symptoms, are closely related. 38 C.F.R. § 4.20. The Court has held that when regulations do not provide diagnostic codes for specific disorders, the VA must evaluate those conditions under codes for similar or analogous disorders. Lendenmann v. Principi, 3 Vet. App. 345, 349-50 (1992). VA considers three factors when deciding whether one condition is related closely enough to another to permit rating by analogy: (1) The functions the condition affects; (2) the condition’s location on the body; and (3) the similarity of symptoms. Id. at 350-51. Once VA rates a claimant’s disability analogously, it must treat the disability as if it is the analogous condition. See Green v. West, 11 Vet. App. 472, 476 (1998). Here, the Veteran’s hypoglycemia is rated under 38 C.F.R. § 4.119, DC 7913. Under that code, a 10 percent rating is assigned when the condition is manageable by restricted diet only. A 20 percent rating is warranted when the condition requires either daily injection of insulin and restricted diet or oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when the condition requires daily injection of insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted when the condition requires daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when the condition requires daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Factual and Procedural Background. By way of history, the Veteran’s STRs show a history of hypoglycemia with symptoms of sweatiness, lightheadedness, and, at times, syncope in 2003, diagnosed as reactive hypoglycemia. The Veteran submitted a claim for service connection for hypoglycemia in December 2004 and, by rating decision dated in November 2005, the RO granted service connection for hypoglycemia, assigning a noncompensable effective fate effective December 21, 2004. In February 2018, the Veteran submitted a claim seeking a disability rating in excess of 10 percent for her service-connected hypoglycemia. See February 2018 VA Form 21-526EZ. In an April 2018 rating decision, the RO increased the Veteran’s disability rating for hypoglycemia from noncompensable to 10 percent disabling effective July 18, 2017, the date of a previous intent to file. Thereafter, the Veteran timely filed a NOD in May 2018. In February 2019, prior to the issuance of a Statement of the Case (SOC), the Veteran opted into RAMP, seeking higher-level review. In a March 2019 RAMP rating decision, the RO continued a 10 percent disability rating for the Veteran’s hypoglycemia. In an August 2019 rating decision, the RO assigned an even earlier effective date of December 21, 2004 for the 10 percent rating for the Veteran’s hypoglycemia. Thereafter, the Veteran submitted a VA Form 10182, appealing, inter alia, the denial of entitlement to a rating in excess of 10 percent for her service-connected hypoglycemia. This is the matter currently before the Board. The Veteran’s VA treatment records indicate that, since in-service diagnosis of hypoglycemia, she has controlled the condition by eating small, frequent meals. See West Los Angeles VAMC records. The Veteran’s private treatment records indicate that she was first prescribed Acarbose, an oral hypoglycemic agent, in November 2018, but has otherwise controlled her condition by eating small, frequent meals. See Kaiser Permanente records, received December 2018. In March 2018, the Veteran was afforded a VA examination in which the examiner noted that the Veteran’s hypoglycemia was managed by restricted diet. The examiner also noted that the Veteran’s activities were regulated as part of the medical management of her hypoglycemia. Specifically, the examiner noted that the Veteran cannot exercise as long as she used to because she gets hypoglycemic symptoms. See March 2018 VA Diabetes Mellitus DBQ. In January 2019, the Veteran was afforded another VA examination, in which the examiner noted that the Veteran’s hypoglycemia was managed by restricted diet and prescribed oral hypoglycemic agent. The examiner also noted that the Veteran’s activities were regulated as part of the medical management of her hypoglycemia, in that exercise was restricted. See January 2019 VA Diabetes Mellitus DBQ. Analysis. 3. A disability rating in excess of 10 percent for service-connected hypoglycemia, prior to November 8, 2018, is denied. 4. A disability rating of 20 percent, but no higher, for service-connected hypoglycemia, for the period beginning November 8, 2018, is granted. The Veteran contends that she is entitled to a rating in excess of 10 percent for her service-connected hypoglycemia. Importantly, the period of consideration begins one year prior to the Veteran’s submission of VA Form 21-526EZ, or February 16, 2017. As noted above, under DC 7913, a 20 percent rating is warranted when the condition requires either daily injection of insulin and restricted diet or oral hypoglycemic agent and restricted diet. Here, the evidence of record indicates that, at all times during the period on appeal, the Veteran has managed her hypoglycemia with restricted diet. See West Los Angeles VAMC records; Kaiser Permanente records; March 2018 VA Diabetes Mellitus DBQ; January 2019 VA Diabetes Mellitus DBQ. Additionally, the evidence of record indicates that the Veteran was first prescribed Acarbose, an oral hypoglycemic agent, on November 8, 2018. See Kaiser Permanent records. As such, the Board finds that, beginning November 8, 2018, the criteria for a rating of 20 percent for service-connected hypoglycemia have been met. However, a rating in excess of 10 percent for service-connected hypoglycemia is not warranted at any point prior to November 8, 2018. In the March 2018 VA examination, the examiner noted that the Veteran’s hypoglycemia was managed by restricted diet only. See March 2018 VA Diabetes Mellitus DBQ. Additionally, the Veteran’s VA treatment records indicate that her hypoglycemia is controlled by restricted diet. See West Los Angeles VAMC records. Moreover, as noted above, the Veteran’s private medical records indicate that her hypoglycemia was not managed with an oral hypoglycemic agent until November 8, 2018. See Kaiser Permanente records. As such, the Board finds that, for the period prior to November 8, 2018, the criteria for a rating of 20 percent for service-connected hypoglycemia have not been met. With respect to a rating in excess of 20 percent beginning November 8, 2018, the Board notes the criteria for a 40, 60, or 100 percent rating require, inter alia, daily injection of insulin. Here, the evidence of record indicates that at no point during the period on appeal has the Veteran’s hypoglycemia required daily injection of insulin. The Veteran has not contended otherwise. Therefore, the Board finds that a rating in excess of 20 percent is not warranted at any point during the period on appeal. See 38 C.F.R. § 4.119, DC 7913. In sum, the Board finds that, prior to November 8, 2018, the preponderance of the evidence is against a finding of entitlement to a rating in excess of 10 percent for the Veteran’s service-connected hypoglycemia. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in this appeal. 38 U.S.C. § 5107(b). The Board also finds that, beginning November 8, 2018, the evidence is at least in equipoise as to whether a 20 percent rating, but no higher, is warranted for the Veteran’s service-connected hypoglycemia. REASONS FOR REMAND As an initial matter, the Board notes that VA is required to consider all theories of entitlement to VA benefits, including via secondary service connection, that are either raised by the claimant or reasonably raised by the record. See Schroder v. West, 212 F.2d 1265, 1271 (Fed. Cir. 2000); Robinson v. Mansfield, 21 Vet. App. 545, 553 (2008). Here, the evidence indicates that a right foot disorder may be related to the Veteran’s service-connected plantar fasciitis with calcaneal spur (left foot condition). See May 2018 Private Opinion. Accordingly, the Board finds it appropriate to recharacterize the Veteran’s claim as one of entitlement to service connection for a right foot condition, to include as secondary to service-connected left foot condition. 5. The claim of entitlement to service connection for a right foot disorder, to include as secondary to service-connected left foot disorder, is remanded. The Board regrets the delay associated with this remand. However, based on a review of the evidence of record, the Board finds that a remand is necessary to allow the Agency of Original Jurisdiction (AOJ) to correct pre-decisional duty to assist errors. First, a remand is necessary as the evidence indicates that there may be relevant private medical records, of which VA is aware, that are not associated with the claims file. Specifically, the record indicates that the Veteran has received treatment from Kaiser Permanente. See Kaiser Permanente records. However, only excerpts of such records have been associated with the claims file. As such, a remand is necessary to allow the AOJ to obtain pertinent medical records. See 38 U.S.C. § 4103(a)(1), (b)(1); Ivey v. Derwinski, 2 Vet. App. 320, 323 (1992). Second, a remand is necessary to provide the Veteran with a VA examination to determine the nature and etiology of her claimed right foot condition. A medical examination is necessary when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing an in-service event, injury, or disease, and (3) an indication that the disability or symptoms may be associated with service or with another service-connected disability, but (4) insufficient medical evidence of record for the Secretary to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C. § 5103A(d)(2). Here, the Board is bound by the March 2019 RAMP rating decision’s favorable findings that the Veteran incurred a right foot contusion in service and has a current diagnosis of right foot heel spur. See 38 C.F.R. § 20.801(a). The Veteran has also submitted evidence indicating that she has current diagnoses of bilateral pes planus, bilateral metatarsalgia, and bilateral plantar fasciitis. See May 2018 Private Foot Conditions DBQ. Further, the evidence indicates that the Veteran’s current right foot disorders may be secondary to her service-connected left foot disorder. See May 2018 Private Opinion. Significantly, the Veteran is presently service-connected for plantar fasciitis with calcaneal spur (formerly shown as residuals of left foot fracture). However, there is no adequate medical opinion regarding the nature and etiology of the Veteran’s claimed right foot disorder. Accordingly, the Board finds that the McLendon requirements are met and the Veteran should be provided a VA examination to determine the nature and etiology of her claimed right foot disorder. In reaching this determination, the Board acknowledges that, in May 2018, the Veteran submitted a statement from Dr. C.N. Bash, a private physician. In this statement, Dr. C.N. Bash opined that the Veteran’s right foot heel spur is likely secondary to the limp gait induced by her service-connected left foot disorder. See May 2018 Private Opinion. However, the Board finds this opinion to be inadequate for adjudication purposes as the opinion utilized the wrong standard and did not provide a rationale in support of the opinion. See Stefl v. Nicholson, 21 Vet. App. 102, 124 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Further, the physician did not provide an opinion regarding the etiology of the Veteran’s right foot pes planus, metatarsalgia, or plantar fasciitis. As such, the opinion is afforded no probative weight. Accordingly, the matter is REMANDED for the following action: 1. With the Veteran’s assistance as appropriate, obtain and associate with the electronic claims file any outstanding pertinent medical records, whether VA or private, to include records relating to treatment at Kaiser Permanente, as well as records relating to treatment at West Los Angeles VAMC from September 2019 to current. Pursuant to 38 C.F.R. § 3.159(e), any efforts to secure these records should be documented in the electronic claims file, and the Veteran should be informed if any of these records are unable to be secured. 2. The Board recognizes the potential practical difficulties in scheduling an examination in light of the COVID-19 epidemic and requests flexibility and understanding in affording the Veteran any warranted examination. 3. After completing the development above, and any additional development warranted by the record, schedule the Veteran for an examination with an appropriate clinician to determine the nature and etiology of her claimed right foot disorder. The entire claims file must be provided to and reviewed by the examiner, and any indicated studies, tests, or evaluations should be performed. The examiner is asked to: (a.) Obtain the Veteran’s detailed lay history, including onset and progression of symptomatology. (b.) For each diagnosed right foot disorder, opine as to whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such disorder had its onset during, or is otherwise related to, the Veteran’s active duty service. (c.) For each diagnosed right foot disorder that is not found to be related to service above, provide the following opinions: i. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such disorder is caused by a service-connected disability, to include the Veteran’s service-connected left foot disorder and any disorder found to be related to service above. ii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such disorder underwent an incremental increase (aggravated), regardless of permanence, by a service-connected disability, to include the Veteran’s service-connected left foot disorder and any disorder found to be related to service above. The term incremental increase in disability means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any incremental increase in disability need not be permanent. The term at least as likely as not does not mean within the realm of medical possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. (Continued on the next page) Any opinion expressed by the examiner should be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the examiner should identify and specifically cite each reference material utilized. If the examiner is unable to offer an opinion without resort to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. APRIL MADDOX Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. T. Martin III, Associate Counsel 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.