Citation Nr: 1320531 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 09-43 511 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim for service connection for right ankle disability. 2. Entitlement to service connection for high cholesterol. 3. Entitlement to service connection for type II diabetes mellitus. 4. Entitlement to service connection for episcleritis. 5. Entitlement to service connection for erectile dysfunction (ED). 6. Entitlement to service connection for left knee disability. 7. Entitlement to service connection for back disability. 8. Entitlement to an initial disability rating higher than 10 percent for venous insufficiency of the left leg. 9. Entitlement to an initial disability rating higher than 10 percent for venous insufficiency of the right leg. 10. Entitlement to an increased (compensable) disability rating for hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from October 1972 to October 1975. This appeal comes before the Board of Veterans' Appeals (Board) from a December 2008 rating decision by the Louisville, Kentucky Regional Office (RO) of the United States Department of Veterans Affairs (VA). In that decision, the RO denied the Veteran's request to reopen a previously denied claim for service connection for right ankle disability, denied service connection for high cholesterol, diabetes, episcleritis, ED, left and right knee disabilities, and back disability, and continued existing disability ratings for venous insufficiency of the left and right legs and for hypertension. In a July 2010 rating decision, the RO granted service connection for right knee disability, resolving the appeal as to that issue. The Board has reviewed both the Veteran's paper claims file and the Veteran's file on the Virtual VA electronic file system, to ensure a total review of the evidence. FINDINGS OF FACT 1. The Veteran did not appeal a November 1979 rating decision denying service connection for right ankle disability. 2. Evidence received since the November 1979 rating decision does not raise a reasonable possibility of substantiating a claim for service connection for right ankle disability. 3. High cholesterol is a laboratory finding and is not a disability for VA compensation purposes. 4. The Veteran's diabetes mellitus was diagnosed many years after service, and was not caused or aggravated by his service-connected hypertension. 5. The Veteran's episcleritis was diagnosed many years after service, and was not caused or aggravated by his service-connected hypertension or right knee arthritis. 6. The Veteran's ED manifested many years after service, and was not caused or aggravated by his service-connected hypertension. 7. Left knee symptoms during service did not result in any finding of chronic or recurrent left knee disorder. Current left knee disability manifested many years after service, and was not caused or aggravated by service-connected right knee disability. 8. Transient back pain accompanying prostatitis during service resolved in service without chronic back pathology or symptoms. Post-service episodes of back pain are not related to any disease or injury in service and were not caused or aggravated by service-connected right knee disability. 9. From July 14, 2008, venous insufficiency of the left leg has been manifested by edema and aching requiring elevation of the leg and compression hosiery, without persistent edema incompletely relieved by elevation, persistent eczema, or ulceration. 10. From July 14, 2008, venous insufficiency of the right leg has been manifested by edema and aching requiring elevation of the leg and compression hosiery, without persistent edema incompletely relieved by elevation, persistent eczema, or ulceration. 11. The Veteran's hypertension requires continuous medication for control. CONCLUSIONS OF LAW 1. The November 1979 rating decision denying service connection for right ankle disability is a final decision. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 3.156 (2012). 2. Evidence received since the November 1979 rating decision is new but is not material to the claim for service connection for right ankle disability. 38 U.S.C.A. §§ 5108, 7104(b) (West 2002); 38 C.F.R. § 3.156. 3. High cholesterol is not a disability and service connection may not be established for it. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 4. The Veteran's diabetes mellitus was not incurred or aggravated in service, is not presumed to be service connected, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 5. The Veteran's episcleritis was not incurred or aggravated in service, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 6. The Veteran's ED was not incurred or aggravated in service, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 7. Current left knee disability was not incurred or aggravated in service, is not presumed to be service connected, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 8. Current back disability was not incurred or aggravated in service, is not presumed to be service connected, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 9. From July 14, 2008, venous insufficiency of the left leg has not met the criteria for a disability rating higher than 10 percent. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.104, Diagnostic Code 7121 (2012). 10. From July 14, 2008, venous insufficiency of the right leg has not met the criteria for a disability rating higher than 10 percent. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.104, Diagnostic Code 7121. 11. The Veteran's hypertension more nearly approximates the criteria for a 10 percent disability rating than those for a 0 percent rating. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.104, Diagnostic Code 7101 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Right Ankle In June 1979 the Veteran submitted a claim for service connection for disabilities including right ankle disability. In a November 1979 rating decision the RO denied service connection for right ankle disability. A rating decision becomes final when a claimant does not file a notice of disagreement (NOD) within one year after a decision is issued. 38 U.S.C.A. § 7105. A rating decision also becomes final if a claimant files a timely NOD, but does not file a timely substantive appeal. 38 U.S.C.A. § 7105. New and material evidence received within a year after the rating decision will be considered as having been filed in connection with the claim. 38 C.F.R. § 3.156(b). If service department records not previously associated with the claims file are received VA will reconsider the claim. 38 C.F.R. § 3.156(c). The Veteran did not file an NOD with the November 1979 rating decision. No relevant evidence was received within one year following that decision, and no additional service department records were received after that rating decision. Therefore, that decision became final. In July 2008 the Veteran requested to reopen a claim for service connection for right ankle disability. A final decision on a claim that has been denied shall be reopened if new and material evidence with respect to that claim is presented or secured. 38 U.S.C.A. §§ 5108, 7104(b). The United States Court of Appeals for Veterans Claims (Court) has ruled that, if the Board determines that new and material evidence has been submitted, the case must be reopened and evaluated in light of all of the evidence, both new and old. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App. 110 (2010). The newly presented evidence need not be probative of all the elements required to award the claim, but only need to be probative in regard to each element that was a specified basis for the last disallowance. Evans v. Brown, 9 Vet. App. 273, 284 (1996). For the purpose of establishing whether new and material evidence has been submitted, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992); Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). In order to reopen a previously and finally disallowed claim, there must be new and material evidence presented or secured since the last time that the claim was finally disallowed on any basis (not only since the last time that the claim was disallowed on the merits). Evans v. Brown, 9 Vet. App. 273 (1996). The November 1979 rating decision is the only final disallowance of the Veteran's claim for service connection for right ankle disability. The Board therefore will consider whether new and material evidence has been submitted since that decision. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury, or for aggravation of a non-service-connected disability by a service-connected disability. 38 C.F.R. § 3.310. Service connection for certain chronic diseases, including arthritis, may be established based upon a legal presumption by showing that it manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Court has explained that, in general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The evidence that was associated with the Veteran's claims file in November 1979 includes service treatment records, VA medical records, and the report of an October 1979 VA medical examination. Medical records show that the Veteran was seen in November 1972 with an eight day history of left foot pain. He reported having twisted the foot while running. The treating clinician observed that the foot was tender, swollen, and bluish in color. The clinician described the injury as a stress reaction. The clinician treated the injury with a soft get cast, rest, and pain medication. The service treatment records are silent for injury or complaints involving the right ankle or foot. On the report of the Veteran's August 1975 medical examination for separation from service, the examiner marked normal for the condition of the Veteran's lower extremities, providing evidence against this claim. VA medical records from 1976 to 1979 are silent for any complaints regarding the right ankle. The report of an October 1979 VA medical examination does not reflect any complaints or findings regarding the right ankle. The evidence that has been added to the claims file since November 1979 includes VA and private medical records and the reports of VA medical examinations. Private medical records from 2006 and 2008 and VA medical records from 2008 to 2010 do not contain any findings of any musculoskeletal disorder of the right or left ankle. On VA examination in October 2008, the examiner reported having reviewed the Veteran's claims file. The Veteran reported that during service he sustained a sprain of his right ankle. He indicated that he had not sought treatment for right or left ankle or foot problems since service. He stated that currently he experienced right ankle pain with prolonged walking, which he rarely did. He did not report having any current left ankle symptoms. The examiner noted the service treatment records showing a left foot injury in 1972. The examiner found that the Veteran had a normal gait. The Veteran's right and left ankles had full ranges of motion with no evidence of pain with motion. Right ankle x-rays showed no fracture or dislocation, and showed moderate soft tissue swelling and calcaneal spurs. The examiner found that there was no diagnosable disorder of the right ankle or left ankle. The examiner provided the opinion that no current right ankle disorder had resulted from the Veteran's left foot injury during service. The examiner explained that the records do not show right ankle injury during service, and that the Veteran did not have current left ankle or foot complaints. The evidence of record in November 1979 did not show that the Veteran sustained right ankle injury during service nor that he a had post-service right ankle disability. The evidence received since November 1979 includes the Veteran's assertion that he sustained right ankle injury during service, which is what the Veteran contended in the past. The new evidence, however, does not help to show that the Veteran has any post-service right ankle disability. The clinician who examined the Veteran in 2008 found no right ankle disorder, and concluded that any right ankle symptoms were not related to any disease or injury in service, including the recorded left foot injury. The new evidence, considered in combination with the old evidence, does not raise a reasonable possibility of substantiating a claim for service connection for right ankle disability. The new evidence therefore is not material to the claim the Veteran seeks to reopen. As VA has not received any evidence that is both new and material, the Board denies reopening of the claim. High Cholesterol The Veteran reports that in the late 1980s he was diagnosed with high cholesterol. He contends that his high cholesterol was caused by or is aggravated by his service-connected hypertension. Private and VA medical records from 2007 forward reflect that the Veteran is on medication to lower cholesterol. The Board acknowledges that the Veteran has high cholesterol. VA has found, however, that diagnoses of hyperlipidemia and elevated cholesterol are laboratory findings and are not, in and of themselves, disabilities for compensation purposes. See Schedule for Rating Disabilities: Endocrine System Disabilities, 61 Fed. Reg. 20,440, 20,445 (May 7, 1996). The evidence does not show that the Veteran's high cholesterol, a laboratory finding, is a manifestation of an underlying disease that is secondary to his service-connected hypertension. Without a current disability, service connection may not be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The preponderance of the evidence therefore is against service connection for high cholesterol, and the Board denies that claim. Diabetes The Veteran reports that he has type II diabetes mellitus that was diagnosed in 1994. He contends that his diabetes was caused by or is aggravated by his service-connected hypertension. The Veteran's service treatment records do not reflect any finding of diabetes, and the Veteran does not contend that diabetes or signs of diabetes began during his service. The preponderance of the evidence is against incurrence or aggravation of diabetes during service. Diabetes mellitus is among the chronic diseases for which service connection may be established based upon a legal presumption by showing that it manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. The Veteran does not contend that his diabetes manifested within a year from his separation from service, and no medical evidence indicates that it manifested during that period. The Board therefore does not presume that the Veteran's diabetes is service connected. Under certain circumstances, service connection for specific diseases, including type II diabetes mellitus, may be presumed if a veteran was exposed during service to certain herbicides, including Agent Orange. 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. §§ 3.307, 3.309(e). A veteran who served on active duty in the Republic of Vietnam during the period from January 9, 1962 to May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. 38 C.F.R. § 3.307(a)(6)(iii). The Veteran does not contend that he served in Vietnam and his service records do not reflect service in Vietnam. There is therefore no basis to presume exposure to an herbicide agent nor service connection for diabetes based on herbicide exposure. The Veteran's claim for service connection for diabetes thus turns on his contention that his diabetes is proximately due to or the result of, or has been aggravated by, his service-connected hypertension. Any increase in severity of a non-service-connected disability that is proximately due to or the result of a service-connected disability, and is not due to the natural progress of the non-service-connected disability, will be service connected. 38 C.F.R. § 3.310(b). The Veteran had elevated blood pressure readings during service. He submitted a claim in 1979 for service connection for hypertension, and the RO granted service connection effective in 1979 for his hypertension. The Veteran has reported that his diabetes was diagnosed in 1994. In the post-service medical records associated with the claims file, records from the 1970s are silent as to diabetes. Records from 2006 forward reflect that the Veteran was under treatment for diabetes. In his July 2008 claim the Veteran stated that his diabetes may have been an outgrowth of his hypertension. He noted that over time his hypertension has required more medications and his capacity for exercise has diminished. He indicated that diminished exercise led to weight gain and the development of diabetes. In the report of a September 2008 VA examination of the Veteran the examiner noted having reviewed the Veteran's claims file. The examiner expressed the opinion that the Veteran's diabetes was not caused or aggravated by his hypertension. The examiner explained that there is no etiological physiologic construct for hypertension causing or aggravating diabetes. The Veteran is competent to report his symptoms and history. As a lay person, he is not competent to provide opinions regarding medical causation. The clinician who examined the Veteran in 2008 is a health care professional, and is competent to address questions of medical causation. The examiner's conclusions that the Veteran's hypertension did not cause or aggravate his diabetes are persuasive. The greater weight of the persuasive evidence thus indicates that the Veteran's hypertension did not cause or aggravate his diabetes. As the Veteran's diabetes did not become manifest during service or the year following service, as he is not presumed to have been exposed to an herbicide agent during service, and as no service-connected disability, including his hypertension, caused or has aggravated his diabetes, the Board denies service connection for diabetes. Episcleritis The Veteran is seeking service connection for the eye disorder episcleritis. During service clinicians tested the Veteran's vision and prescribed corrective lenses in October 1972, March 1973, and January 1975. His service treatment records do not reflect any complaints of eye discomfort or findings of eye disorder other than refractive error. Records of VA medical treatment of the Veteran in 1976 to 1979 are silent for eye symptoms or findings. In a July 2008 claim the Veteran reported that he had developed episcleritis. He contended that the episcleritis developed due to hypertension, diabetes, or arthritis. In a September 2008 treatment report, private ophthalmologist D. T. G., M.D., noted that he was seeing the Veteran as a five month follow-up for ocular hypertension, diabetes, and bilateral episcleritis. The Veteran reported that his eyes had been red, irritated, tender, and very dry. While Dr. G. noted that the Veteran had ocular hypertension, he did not address whether the Veteran's essential hypertension caused or worsened his episcleritis. In VA outpatient treatment in January 2009, the Veteran reported that his last eye examination, in September 2008, had shown episcleritis. That history was noted again in treatment notes from 2009 and 2010. The medical records from 2008 through 2010 which contain notation of the Veteran's episcleritis do not discuss the origin, cause, or progression of that condition in the Veteran's case. Service connection is established for the Veteran's hypertension and for arthritis in his right knee. The Veteran has type II diabetes mellitus. Service connection is not established for that disease. The Veteran is competent to report his symptoms and history. As a lay person, he is not competent to provide opinions regarding medical causation, including whether one medical condition caused or aggravated another. There is no medical evidence, and thus no competent evidence, supporting a link between the Veteran's recent episcleritis and disease or injury in service or service-connected hypertension or right knee arthritis. The preponderance of the evidence thus is against service connection for episcleritis. ED The Veteran reports that he has ED that developed after service. He contends that his ED may have developed as a result of, or be aggravated by, one or more of his service-connected disabilities. The Veteran's disabilities for which service connection is established include hypertension, prostatitis, venous insufficiency of the left and right legs, and right knee arthritis. During service the Veteran had outpatient treatment in September 1974 for a burning sensation with urination. The treatment notes do not indicate that the Veteran reported ED at that time. The treating clinician found that the Veteran's prostate was tender and slightly boggy. The clinician's impression was acute prostatitis. The remainder of the service treatment records also are silent for reports of ED. The claims file contains records of VA medical treatment of the Veteran in 1976 to 1979. In May 1977 the Veteran reported an episode of rectal bleeding. In September 1977 he reported dysuria that was worse after intercourse. The examiner's impression was traumatic urethritis. In September 1978 the Veteran reported burning and itching with urination and frequent urination. The 1976 to 1979 treatment records do not contain any report of ED. In June 1979 the Veteran submitted a claim for service connection for several disorders including a prostate disorder. On VA medical examination in October 1979 the Veteran reported a history of episodes of painful urination during and after service. In a November 1979 rating decision the RO granted service connection for prostatitis. The RO also granted service connection for hypertension. Records of private medical care of the Veteran in 2006 through 2008 reflect treatment for hypertension and diabetes mellitus. In a July 2008 claim the Veteran contended that medications for hypertension, diabetes, and arthritis resulted in medically induced impotence. The Veteran had a VA hypertension examination in July 2008. He reported that he had been on medication for hypertension since 1988 and that he was diagnosed with diabetes in 1994. He stated that he had ED. He indicated that he was on multiple medications for hypertension, and that the side effects of those medications was dizziness and sexual dysfunction. He related that ED symptoms began in about 1988, about the same time he began medication for hypertension. On the July 2008 examination the Veteran's prostate was normal. The Veteran had a VA diabetes examination in September 2008. He indicated that his diabetes was diagnosed in the 1990s and that presently he was on oral medications for diabetes. Medical history reported also included his hypertension. It was noted that the Veteran had ED. The examiner indicated that diabetic neuropathy was a contributing cause of ED. The examiner provided the opinion that the Veteran's ED was a complication of diabetes. The examiner explained this opinion based on the onset of the Veteran's ED in relation to the onset of his diabetes. The RO asked the clinician who examined the Veteran in September 2008 to provide an opinion as to whether the Veteran's ED was caused by his hypertension. The examiner provided the opinion that the Veteran's ED is not caused by his hypertension. The examiner explained that the Veteran had a long history of diabetes, and that his ED was caused by his diabetes. The examiner stated that diabetic neuropathy was a leading cause of ED, and that hypertension does not cause ED. The examiner also opined that the Veteran's hypertension did not permanently aggravate his ED. Records of VA treatment of the Veteran in 2009 and 2010 reflect diagnoses of hypertension, diabetes, and ED, without addressing the etiology of those disorders. The Veteran contends that his ED is caused or aggravated by his service-connected disabilities, including hypertension. A VA clinician who examined the Veteran and reviewed his records concluded that his diabetes (which is not service connected) caused his ED and that his hypertension did not cause or aggravate his ED. The opinion of the clinician, who has health care training, is more persuasive on matters of medical causation than that of the Veteran, who does not have such training. Importantly, a review of treatment records fails to indicate any connection between ED and service or a service connection disability, which only supports the negative medical opinion regarding a condition which did not exist until many years after service. Thus, the preponderance of the evidence is against service connection for the Veteran's ED. Left Knee Disability The Veteran appealed the RO's denial of service connection for left and right knee disabilities. The RO subsequently granted service connection for right knee arthritis. The Veteran has continued his appeal for service connection for left knee disability. He essentially contends that left knee disability began during service and has been aggravated by his service-connected right knee disability. During service the Veteran received treatment in November 1972 for left foot pain and swelling following a twisting injury. The treating clinician described the left foot condition as a stress reaction and prescribed a soft gel cast. The Veteran was seen in a podiatry clinic in October 1973 and January 1975. In January 1975 the Veteran reported pain in the arches of both feet and in both knees during prolonged standing. The treating clinician found that the Veteran had symptomatic pes planus. The clinician prescribed arch supports. On a medical examination in January 1975 the Veteran reported having pain in both knees and in the arches of both feet after running or prolonged walking. The examiner noted pes planus and checked normal for the condition of the Veteran's lower extremities. On the report of a June 1975 medication the examiner checked normal for the condition of the Veteran's lower extremities, providing factual evidence against his own claim. A VA treatment record from August 1976 reflects that the Veteran was seen for knee symptoms. The treatment note indicates that an arthrogram was negative, and that further studies should wait until the knee was swollen again. The note did not specify which knee had been swollen. In June 1979 the Veteran submitted a claim for service connection for several disorders including residuals of right ankle sprain. On VA medical examination in October 1979 the Veteran did not report having any current complaints involving either lower extremity. In a November 1979 rating decision the RO denied service connection for right ankle sprain. The claims file contains records of private treatment in 2006 for right knee problems. In March 2006 the Veteran reported a history of right knee arthroscopic surgery several years earlier. He related a current three week history of right knee pain, swelling, locking, and giving way. The treating physician observed that the Veteran walked with an antalgic gait. A right knee MRI showed right knee chondromalacia patella. The Veteran had right knee arthroscopic surgery in May 2006, which showed arthritic change. After surgery he had physical therapy. In November 2006 the Veteran reported having left knee symptoms similar to those in the right knee. A treating physician noted that both knees had effusion and tenderness, and stated that the Veteran had bilateral knee arthritis that was expected to be progressively bothersome. In a July 2008 claim the Veteran reported that during service he sustained a right ankle injury in service and experienced right knee pain and swelling. He stated that after service he had a right knee disorder addressed by two surgeries. He related that he had walked with a cane since 1994. He stated that problems had spread to his left knee. On a VA joints examination in December 2009 the examiner reported having reviewed the Veteran's claims file. The Veteran indicated that he always used a cane when walking. The examiner observed that the Veteran had an antalgic gait. The left and right knees each had motion from 0 to 120 degrees. There was objective evidence of pain with motion of the right knee, but no objective evidence of pain with motion of the left knee. The examiner found that the Veteran had right knee arthritis. The examiner did not provide a diagnosis regarding the Veteran's left knee. During service the Veteran reported left and right knee pain in January 1975, but no clinician found any chronic or recurrent disorder affecting the left knee. Examiners indicated in January 1975 and June 1975 that the Veteran's lower extremities, which includes his left knee, were normal. The greater weight of the evidence thus tends to indicate that he did not have any chronic left knee disorder when he was separated from service in October 1975. The record of August 1976 treatment does not indicate which of the Veteran's knees had been symptomatic. In any case the arthrogram at that time was negative and did not show arthritis in the knee that was viewed. As there is no evidence that arthritis manifested in the Veteran's left knee during the year following his separation from service, the Board does not presume that any current left knee arthritis is service connected. In 2006, many years after service, the Veteran told the private physician who treated his right knee chondromalacia and arthritis that he had similar symptoms in his left knee. That physician indicated that the Veteran had arthritis in both knees. Neither the private physician nor the VA physician who examined the Veteran in 2009 has indicated that the Veteran's current left knee disability was incurred during service. Considering the medical examination evidence that the Veteran did not have a chronic left knee disability at separation from service and the lack of medical evidence relating current left knee disability to service, the preponderance of the evidence is against direct service connection for current left knee disability. The Veteran claims that his service-connected right knee disability caused or aggravates his current left knee disability. There is evidence that the Veteran uses a cane when he walks and that he has an antalgic gait. The Veteran is competent to relate the symptoms he has had and the order in which they arose. As he is a lay person his statements are not competent medical evidence on issues of whether one medical disorder caused or worsened another disorder. No medical professional has indicated that there is any likelihood that the Veteran's right knee disability and the resultant gait caused or has worsened disability of his left knee. There is nothing in the treatment records that indicate such a connection. The Veteran's own statements on this point have been, at best, unclear, with the Veteran raising different theories at different times. In summary, as the Veteran did not have a chronic left knee disorder during service, as left knee arthritis did not become manifest during the year following service, as current left knee disability was not documented until many years after service, and as right knee disability did not cause or aggravate left knee disability, the Board denies service connection for left knee disability. Back Disability The Veteran is seeking service connection for a back disability. He essentially contends that a back disorder began during service or was caused by an altered gait resulting from his service-connected right knee arthritis. The Veteran's service treatment records do not reflect any report of back injury. In September 1974 the Veteran sought treatment for a burning sensation with urination accompanied by pain in the right side of his low back. The treating clinician's impression was acute prostatitis. The remainder of the service treatment records are silent for back symptoms. On service examinations in January and July 1975 the examiners each checked normal for the condition of the Veteran's spine. The Veteran was separated from service in October 1975. After service the Veteran had VA treatment in October 1976 for low back pain. He reported that he had pain after lifting heavy equipment but felt better on the day that he was seen. On follow up in December 1976 he reported that his back pain was better, and that the remaining pain was centered between the scapula in the lower thoracic area. A clinician prescribed pain medication. In January 1977 the Veteran reported that the symptoms were much better. In private treatment in May 2008 the Veteran reported that he had aches, pains, and popping in both knees and in his back. In a July 2008 claim the Veteran indicated that because of right knee disability he had walked with a cane since 1994. He stated that his right knee arthritis had spread to his spine. In VA treatment in 2009 and 2010 the Veteran indicated that he had pain in his upper back and neck. The Veteran has not indicated that x-rays of his spine have been taken. There is no record of spine x-rays and no diagnosis of arthritis of any part of the spine. In the absence of spine arthritis there is no basis for presumption of service connection for spine arthritis. The Veteran had low back pain accompanying prostatitis on one occasion during service. His service treatment records do not show, and he does not contend, that during service he had back injury or chronic or recurrent back symptoms. After service, in 1976 and 1977, he had treatment for back pain. Symptoms reportedly improved with treatment and time. The treating clinicians did not diagnose a chronic back disorder. For a long stretch of years, 1978 to 2007, there is no contemporaneous account of back symptoms. From 2008 forward, when the Veteran reported back pain, he did not contend that the pain had been continuous or even frequently recurrent since service. He did not indicate when the current back pain arose. In some instances he attributed the current back pain to arthritis in his right knee. In the absence of clear evidence of a injury, disease, or even persistent or recurrent symptoms affecting the back during service, and in the absence of evidence or even a contention that back symptoms began during service and continued or recurred after service, the preponderance of the evidence is against service incurrence of current back disability. The Veteran contends that service-connected right knee disability caused or aggravates current back disability. As noted above, medical records reflect that the Veteran uses a cane and has an antalgic gait. No medical professional has indicated, however, that there is any likelihood that the Veteran's right knee disability and the resultant gait caused or has worsened current back disability. Again, the Veteran is competent to relate the symptoms he has had and the order in which they arose, but his statements are not competent medical evidence as to whether one medical disorder caused or worsened another disorder. The preponderance of the evidence therefore is against the claim that right knee disability caused or aggravated left knee disability. There is simply nothing that connects the conditions at issue except the lay medical opinions of the Veteran, who simply does not have the medical expertise to be providing such medical opinions and has, as noted above, provided multiple medical causation opinions attempting to connect one disability to another disability without medical foundation, and not always consistently, limiting the probative value of those medical opinions. As the preponderance of the evidence is against presumptive, direct, or secondary service connection, the Board denies service connection for back disability. Venous Insufficiency of the Left and Right Legs The Veteran appealed the initial disability ratings of 10 percent each that the RO assigned for venous insufficiency in his left and right legs. VA assigns disability ratings by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. 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 determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. The Court has held that, at the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). As the Veteran appealed the initial disability rating that the RO assigned for venous insufficiency of the left and right legs, the Board will consider the evidence for the entire period since the July 14, 2008, effective date of the grant of service connection, and will consider whether staged ratings are warranted. The RO has evaluated that disorder under 38 C.F.R. § 4.104, Diagnostic Code 7121. That code provides rating criteria as follows: Massive board-like edema with constant pain at rest ......................................................... 100 percent Persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration ........................................................... 60 percent Persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration ........................ 40 percent Persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema ................................................... 20 percent Intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery .. 10 percent Asymptomatic palpable or visible varicose veins ... 0 percent In private treatment in July 2007 the physician found that the Veteran's venous insufficiency was better, providing evidence against this claim. The physician indicated that the Veteran needed weight loss. The physician noted that there had been no further itch or pain in the Veteran's legs. On VA examination in July 2008, the examiner noted that the Veteran had chronic venous stasis in both lower extremities. There was 1+ peripheral edema from the ankle to the upper calf in each leg. In VA treatment in January 2009 there was 1-2+ edema in each leg. There were positive pedal pulses. The treating clinician indicated that the bilateral chronic venous insufficiency was stable. The clinician indicated that the Veteran should elevate his legs and follow a low salt diet. The Veteran asked for new compression hose to replace old ones. VA supplied new hose in February 2009. In July 2009 a treating clinician found that the Veteran's venous insufficiency was stable and that compression hose should be used as necessary. Examination and treatment records do not show that the Veteran's lower extremity venous insufficiency has been manifested by persistent edema that is incompletely relieved by elevation of the legs. The records do not indicate that he has had persistent eczema on his legs, nor ulceration. The manifestations and effects of his venous insufficiency thus have not, in either leg, met or approached the criteria for a rating higher than the existing 10 percent rating. While the Board has considered the issue of whether it should obtain another examination in the case, the critical question is whether the Veteran has persistent edema and a single examination will not provide such information. A review of the treatment records over time, as a whole, VA a private, provides evidence against the claim that the Veteran has persistent edema at this time. In this regard, it is important for the Veteran to understand that there is some evidence in this case that does not support the current evaluation. The Board has considered whether the record raises the issue of unemployability, such that unemployability must be considered. See Rice v. Shinseki, 22 Vet. App. 447 (2009). A review of the record reveals that the Veteran holds full time employment as a transportation network specialist. He has not indicated that his venous insufficiency of the legs and other service-connected disabilities make him unable to hold employment. In this case, then, the record does not raise the issue of unemployability. When there is an exceptional disability picture, such that the rating schedule criteria do not reasonably describe a claimant's disability level and symptomatology, an RO may refer a case to the VA Under Secretary for Benefits or to the Director of the VA Compensation and Pension Service for consideration of an extraschedular rating. See 38 C.F.R. § 3.321(b)(1) (2012); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008). Extraschedular ratings are limited to cases in which it is impractical to apply the regular standards of the rating schedule because there is an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment. 38 C.F.R. § 3.321(b)(1). Venous insufficiency in the Veteran's left and right legs has not required frequent hospitalizations and has not markedly interfered with his employment. The rating schedule criteria address the Veteran's venous insufficiency manifestations of edema, aching, and the need for elevation and compression hosiery. The rating criteria provide for higher ratings for greater impairment than is present in this case. The regular rating criteria thus are sufficient to the circumstances of this case, and it is not necessary to refer the ratings for venous insufficiency of the left and right legs for consideration of extraschedular ratings. Hypertension The RO established service connection for the Veteran's hypertension effective in 1979, and assigned a 0 percent, noncompensable disability rating. In August 2007 the Veteran submitted a claim for an increased disability rating for hypertension. He noted that he was taking several medications for it. The Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Therefore, the Board will consider whether different ratings are warranted for different time periods. The rating schedule provides the following criteria for evaluating hypertension. Diastolic pressure predominantly 130 or more ..... 60 percent Diastolic pressure predominantly 120 or more ..... 40 percent Diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more ................ 20 percent Diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control ................................. 10 percent 38 C.F.R. § 4.104, Diagnostic Code 7101. On VA medical examination in October 1979 the examiner found that the Veteran's hypertension was untreated and out of control. Blood pressure readings were 134/90, 138/96, and 144/100. Records of private and VA treatment from 2007 forward reflect that the Veteran was on medications for hypertension. On VA examination in July 2008 the Veteran reported that from diagnosis in the 1970s his hypertension was treated with diet and exercise, and that he had been on medication for hypertension since about 1988. He stated that over time control of his hypertension had required increased doses and multiple medications. At the time of the examination he was on multiple daily medications for hypertension. The blood pressure readings during the examination were 133/68, 139/76, and 135/84. In VA treatment in January 2009 the Veteran's blood pressure was 166/91. In subsequent readings in 2009 and 2010 the diastolic pressure was less than 160. In blood pressure readings in private and VA treatment records there have been no diastolic readings of 110 or more and no systolic readings of 200 or more. The Veteran's statements and medical records show that the Veteran's hypertension requires continuous medication for control. The claims file does not contain medical records from the period directly before treatment with medication was initiated; so there is no direct evidence as to whether the Veteran's diastolic pressure was predominantly 100 or more before he was on medication. The requirement of medication for control, however, is credibly reported for a many year period and medically documented from 2007 forward. The Board cannot know what the Veteran's diastolic pressure would be without medication at this time. Considering the requirement of medication for control, the Board finds that the manifestations of the Veteran's hypertension more nearly approximate the criteria for a 10 percent rating than those for a 0 percent rating. Resolving reasonable doubt in the Veteran's favor, the Board grants a 10 percent rating for hypertension. Clearly the post-service medical records would provide highly probative evidence against any higher evaluation as it does not clearly support the 10 percent evaluation. As noted above, the Veteran holds full time employment. He has not indicated that his hypertension and other service-connected disabilities make him unable to hold employment. Therefore in this case the record does not raise the issue of unemployability. The Veteran's hypertension has not required frequent hospitalizations and has not markedly interfered with his employment. The rating schedule criteria address the Veteran's hypertension manifestations of elevated blood pressure and requirement of medication for control. The rating criteria provide for higher ratings for greater impairment than is present in this case. The regular rating criteria thus are sufficient to the circumstances of this case, and it is not necessary to refer the rating for hypertension for consideration of an extraschedular rating. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2011)) redefined VA's duty to assist a claimant in the development of a claim for VA benefits. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The Court has stated that the requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Notice in a new and material evidence claim (1) must notify a claimant of the evidence and information that is necessary to reopen the claim and (2) must notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying benefit sought by the claimant. Kent v. Nicholson, 20 Vet. App. 1 (2006). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The RO provided the Veteran VCAA notice in letters issued in June 2008, July 2008, and January 2009. Those letters addressed the information and evidence necessary to substantiate claims for service connection and informed the Veteran how VA assigns disability ratings and effective dates. The July 2008 letter informed the Veteran of the type of evidence necessary to reopen a previously denied claim. The letters also addressed who was to provide the evidence. The claims file contains the Veteran's service treatment records, post-service treatment records, and VA examination reports. The Veteran has not reported the existence of any relevant evidence that is not associated with the claims file. In an October 2009 substantive appeal, the Veteran stated that he was unable to get a copy of his service treatment records because he was told that VA has those records. The Veteran may request a copy of those records from the RO. While the Veteran indicates that he has not yet received those records for review, the records are associated with the claims file. The RO and the Board have reviewed them. There is no indication that any of the records are missing. In this regard the Board has considered the issue of whether it should remand the case to RO, delaying the full adjudication of this case, in order to have the RO provide the Veteran with a copy of this service treatment records, notwithstanding the fact that there is no indication in this record that the Veteran ever sent a letter to the RO asking for a copy of his service treatment records, and notwithstanding the fact that the RO's statement of the case/supplemental statement of the case clearly cited pertinent service records. In making this determination the Board has undergone a detailed review of the Veteran's case. In this regard, the Veteran's primary claims regarding service connection have not been based on direct service connection but on secondary service connection (the claim that one disability has caused another problem), therefore, service treatment records would not be pertinent regarding those claims. Regarding the Veteran's increased rating claims, the service treatment records would have even less relevance to the Veteran's case, in which it is the nature and extent of the disability at this time, not while the Veteran was in service, that is the critical issue. Therefore, the Board finds it appropriate to proceed with review of the issues on appeal based on review of the relevant evidence. The Veteran's contentions as a whole must also be considered. The VA examination reports are adequate for addressing the claims for service connection for high cholesterol, diabetes, and ED, and for higher ratings for venous insufficiency of the left and right legs. The VA examinations that have been performed have not addressed the Veteran's claims that episcleritis, left knee disability, and back disability each have developed as a result of or have been aggravated by his service-connected hypertension, prostatitis, venous insufficiency of the left and right legs, and/or right knee arthritis. VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service or with another service-connected disability, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Post-service medical records contain reports of symptoms of episcleritis, left knee disability, and back disability. The record does not indicate, however, that any current episcleritis, left knee disability, or back disability may be associated with the Veteran's service or with his service-connected disabilities. The Veteran did not have signs of episcleritis in service, and no one competent on matters of medical causation has supported a link, or even indicated a link, between recent episcleritis and any service-connected disability. The record does not indicate that current left knee disability may be associated with any lasting symptoms in service or with right knee disability. The record does not indicate that the Veteran had injury, disease, or persistent or recurrent symptoms affecting the back during service or that post-service back disability may be associated with transient back pain symptoms during service or with right knee disability. The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service (as in this case) would not suffice to meet the standards, as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, as the only evidence that the Veteran's claimed disability is related to military service (or a service connected disability) is the conclusory generalized lay statements of the Veteran, which are unsupported by even speculative medical evidence. Therefore VA is not obliged to provide a medical examination or obtain a medical opinion with respect to the claims for service connection of any of those conditions, based on a review of the evidence as a whole. The Board finds that the Veteran was notified and aware of the evidence needed to substantiate the claims on appeal, as well as the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran has actively participated in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process, and he has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication nor to have caused injury to the Veteran's interests. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless, and does not prohibit consideration of the claims on the merits. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). ORDER Reopening of the previously denied claim for service connection for right ankle disability is denied. Entitlement to service connection for high cholesterol is denied. Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for episcleritis is denied. Entitlement to service connection for ED is denied. Entitlement to service connection for left knee disability is denied. Entitlement to service connection for back disability is denied. From July 14, 2008, entitlement to a disability rating higher than 10 percent for venous insufficiency of the left leg is denied. From July 14, 2008, entitlement to a disability rating higher than 10 percent for venous insufficiency of the right leg is denied. Entitlement to a 10 percent disability rating for hypertension is granted, subject to the laws and regulations controlling the disbursement of monetary benefits. ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs