Citation Nr: 1329685 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 07-09 815 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an increased initial rating for residuals of Epstein-Barr Syndrome, manifested by chronic fatigue syndrome and fibromyalgia, currently rated as 60 percent disabling. 2. Entitlement to an increased initial rating for acne affecting the face, chest, and back, currently rated as 10 percent disabling since February 18, 1998, and 30 percent disabling since December 16, 2008. 3. Entitlement to an increased rating for right knee patellofemoral syndrome with IT band tendonitis, currently rated as 10 percent disabling. 4. Entitlement to an increased rating for left knee patellofemoral syndrome with IT band tendonitis, currently rated as 10 percent disabling. 5. Entitlement to an increased rating for degenerative changes sacroiliac joints, currently rated as 10 percent disabling. 6. Entitlement to service connection for a fungal skin condition affecting the left foot. 7. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for uterine cyst disability. 8. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Tenner, Counsel INTRODUCTION The Veteran served on active duty from June 1988 to February 1998. This case comes before the Board of Veterans' Appeals (Board) on appeal from August 2005, February 2008, November 2008, and July 2009 decisions rendered by the Phoenix, Arizona Regional Office (RO) of the Department of Veterans Affairs (VA). In the August 2005 decision, the RO denied an evaluation in excess of 60 percent for Epstein-Barr Syndrome. In the February 2008 decision, the RO reopened but denied the claims for service connection for uterine cysts and hypertension. In the November 2008 decision, the RO granted service connection and assigned an initial 10 percent disability rating for acne to the face, chest and back. The 10 percent rating was effective February 18, 1998. During the pendency of the appeal, the RO assigned a 30 percent rating, effective December 16, 2008. Finally, the July 2009 decision addressed the remaining issues on appeal. The issues of entitlement to service connection for uterine cysts/fibroids, hypertension, and a fungal skin condition affecting the left foot are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. The following determination is based on review of the Veteran's claims file in addition to his Virtual VA " eFolder ." FINDINGS OF FACT 1. Epstein-Barr syndrome does not result in debilitating fatigue that impairs the Veteran's ability to undertake routine daily activities or conduct self care. 2. For the period prior to December 16, 2008, acne affected the face, chest, and back, and was well-controlled and did not require corticosteroids or immunosuppressive drug therapy. Since December 16, 2008, acne to the face, chest, and back did not result in ulceration or extensive exfoliation or crusting, and systemic or nervous manifestation or exceptional repugnance. It does not affect 40 percent of the entire body or more than 40 percent of exposed areas. 3. Even considering the Veteran reports of pain, the Veteran's right knee patellofemoral syndrome with IT band tendonitis disability does not result in limited flexion to 45 degrees or extension limited to 10 degrees; and, there is no evidence of ankylosis, recurrent subluxation or lateral instability, removal of semilunar cartilage, impairment of the tibia and fibula, or a tender or painful scar. 4. Even considering the Veteran reports of pain, the Veteran's left knee patellofemoral syndrome with IT band tendonitis disability does not result in limited flexion to 45 degrees or extension limited to 10 degrees; and, there is no evidence of ankylosis, recurrent subluxation or lateral instability, removal of semilunar cartilage, impairment of the tibia and fibula, or a tender or painful scar. 5. The Veteran's lumbar spine disability is manifested by 80 degrees forward flexion in the thoracolumbar spine, extension from 0 to 40 degrees, lateral bending from 0 to 30 degrees, and rotation from 0 to 35 degrees. The Veteran did not have guarding severe enough to result in an abnormal gait or abnormal spinal contour and her lumbar spine disability did not result in any incapacitating episodes requiring bed rest prescribed by a physician and treatment by a physician. 6. In an unappealed November 1998 and February 2001 decisions, the RO denied service connection for uterine cysts. 7. In an October 2002 decision, the Board denied service connection for hypertension. 8. Evidence received since the most recent final denial is new and material and raises a reasonable possibility of substantiating the claim for service connection for uterine cysts. 9. Evidence received since the most recent final denial is new and material and raises a reasonable possibility of substantiating the claim for service connection for hypertension. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 60 percent for Epstein-Barr Syndrome have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.88, Diagnostic Codes 6354 (2012). 2. The criteria for an initial rating for acne affecting the face, chest, and back, currently rated as 10 percent disabling since February 18, 1998, and 30 percent disabling since December 16, 2008, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012)38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7806 (as in effect prior to and since August 30, 2002). 3. The criteria for a disability rating in excess of 10 percent for right knee patellofemoral syndrome with IT band tendonitis have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5024, 5256-5263 (2012). 4. The criteria for a disability rating in excess of 10 percent for left knee patellofemoral syndrome with IT band tendonitis have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5024, 5256-5263 (2012). 5. The criteria for an evaluation in excess of 10 percent for degenerative changes sacroiliac joints have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5242 (2012). 6. The November 1998 and February 2001 decisions, in which the RO denied service connection for uterine cysts are final. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.104(a), 20.200, 20.1103. 7. The October 2002 Board decision that denied entitlement to service connection for hypertension is final. 38 U.S.C.A. § 7103 (West 2002); 38 C.F.R. § 20.1100 (2012). 8. The criteria to reopen a claim of entitlement to service connection for uterine cysts have been met. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 9. The criteria to reopen a claim of entitlement to service connection for hypertension have been met. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). This notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The Veteran's acne claim arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA with regard to this issue. Regarding the remaining claims on appeal, the Veteran was provided with notice of what types of information and evidence were needed to substantiate her claims for higher disability ratings in August 2008 and April 2009 VCAA letters. These letters were issued prior to the initial adjudication of the claims. A July 2007 letter provided information as to how to substantiate her claims to reopen service connection for uterine cysts and hypertension. See Kent v. Nicholson, 20 Vet. App. 1 (2006). This letter was also furnished prior to the adjudication of the claims to reopen. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting her in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished relative to the claims adjudicated therein, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA treatment and examination. Numerous private treatment records have been supplied. Moreover, her statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. While the Veteran identified that she was in receipt of Social Security Administration (SSA) disability benefits during a hearing in March 2000, she indicated that SSA determined she was disabled due to fibromyalgia and that SSA relied on VA records in making that determination. Here, the Veteran has not asked VA to obtain these records, nor has she indicated how they are relevant to her claims. While they are potentially relevant to the claim for a higher rating for Epstein-Barr Syndrome, because SSA benefits were awarded prior to 2000 and because SSA relied on VA records in making that determination, the Board will not delay the adjudication of this case by remanding the matter for the records. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010)("It is not the case that the government must obtain records in every case in order to rule out their relevance.") The Board has also reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. Examinations were conducted and those examinations, as discussed herein, are considered adequate for rating and decisional purposes. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims decided herein. II. Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practicably be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Although the claimant's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection 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. Francisco v. Brown, 7 Vet. App. 55 (1994). When a claimant is awarded service connection and assigned an initial rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). In Hart v. Mansfield, 21 Vet. App. 505, 511 (2007), the CAVC extended entitlement to staged ratings to claims for increased disability ratings where "the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." A. Epstein-Barr Syndrome In a June 2003 decision, the Board granted entitlement to service connection for residuals of Epstein-Barr virus. In February 2004, the RO implemented that decision and assigned an initial 60 percent evaluation, effective February 18, 1998. In assigning the rating, the RO found that Epstein-Barr residuals included symptoms of previously service-connected chronic fatigue syndrome and fibromyalgia. The RO determined that the previously separate evaluations for chronic fatigue syndrome and fibromyalgia would be combined and the effects of Epstein-Barr residuals would be rated under 38 C.F.R. § 4.88a, Diagnostic Code 6354. The Veteran has not disagreed with the RO's assignment of the particular Diagnostic Code to rate the disability. Indeed, for VA purposes a diagnosis of chronic fatigue syndrome often includes consideration of muscle aches and migratory joint pains; symptoms that are considered under 38 C.F.R. § 4.88a. See 38 C.F.R. § 4.88a. Hence, consideration of the claim under Diagnostic Code 6354 is appropriate. In February 2005, the RO received a statement from the Veteran asking the RO to "reconsider the level of disability granted for Epstein-Barr Syndrome." The Board finds that her statement may be interpreted as a disagreement with the initial disability rating assigned. As noted in the Introduction, in the August 2005 decision, the RO denied an initial evaluation in excess of 60 percent for Epstein-Barr with chronic fatigue syndrome and fibromyalgia. Accordingly, the Board has reviewed the evidence since the February 1998 effective date of the grant of service connection. Epstein-Barr manifested by chronic fatigue syndrome and fibromyalgia is currently rated under 38 C.F.R. § 4.88b, Diagnostic Code 6399-6354, indicating an unlisted disability rated by analogy to chronic fatigue syndrome. Diagnostic Code 6354 states that chronic fatigue syndrome includes debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms. A 60 percent rating is assigned for signs and symptoms of chronic fatigue syndrome that are nearly constant and restrict routine daily activities to less than 50 percent of the pre-illness level, or signs and symptoms that wax and wane, resulting in periods of incapacitation of at least six weeks total duration per year. A 100 percent rating is assigned for signs and symptoms of chronic fatigue syndrome that are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. For the purpose of rating chronic fatigue syndrome, the condition will be considered incapacitating only when it requires bed rest and treatment by a physician. 38 C.F.R. § 4.88b, Diagnostic Code 6354, Note (2012). Here, while the evidence shows longstanding reports of chronic fatigue and muscle aches, the weight of the evidence does not show that residuals of Epstein-Barr result in debilitating fatigue that impairs her ability to undertake routine daily activities or conduct self care. For instance, on initial VA examination in July 1998, there were finding of muscle aches and chronic fatigue; however, the examiner did not describe any debilitating effects. Similarly, a February 1999 Vocational Rehabilitation assessment noted the reports of fatigue and fibromyalgia but did not describe any constant debilitating fatigue so severe as to interfere with daily activities or self care. Moreover, while a March 2005 VA examination revealed that she was unable to maintain employment as a result of her symptoms; symptoms of chronic fatigue syndrome or fibromyalgia were not so severe as to correspond to the criteria for a 100 percent disability rating. Treatment did not require doctor prescribed bedrest. It is significant to note that she was awarded a total disability evaluation based on individual unemployability, however, the rating criteria for that evaluation differs from the criteria for a 100 percent under Diagnostic Code 6354 noted above. See 38 C.F.R. § 4.16. It is also important to note that she is in receipt of a separate 70 percent disability evaluation for a service-connected psychiatric disability. In this respect, the Board acknowledges a December 2008 letter from her treating psychiatrist which indicates that chronic fatigue syndrome impairs her ability to manage ordinary household responsibilities. While this finding reveals a significant level of psychological impairment, it is entirely inconsistent with VA outpatient treatment records which do not reveal cognitive impairment due to Epstein-Barr. For instance, on VA examination in June 2012, the examiner, who reviewed the Veteran's VA treatment records, found that chronic fatigue syndrome did not result in any neuropsychiatric symptoms or cognitive impairment. Moreover, as it pertains to the 100 percent rating criteria, the examiner found that the chronic fatigue syndrome disability did not result in periods of incapacitation and that symptoms only restricted routine activities to less than 50 percent of the pre-illness level. Finally, while the examiner agreed that the disability resulted in functional impairment, she found that the Veteran was still able to sit, stand, and walk as needed, and perform sedentary work. These findings do not support the claim for a disability rating in excess of 60 percent. The Board acknowledges the Veteran's subjective complaints throughout the appeal period, such as reports of fatigue and muscle pain. The Veteran is competent to report her subjective symptoms. These lay observations are credible, but must be evaluated in light of the rating schedule described above. The lay statements have been considered, however, the weight of evidence of record has not shown the severity required for a higher schedular at any other time, as discussed above. See Fenderson v. West, 12 Vet. App. 119 (1999). B. Acne As noted, the Veteran appeals the initial rating assigned for acne affecting the face, chest, and back. The disability is rated as 10 percent disabling since February 18, 1998, and 30 percent disabling since December 16, 2008. The initial rating was assigned by the RO in a November 2008 rating decision. In assigning the effective, date, the RO found that the Veteran's claim was pending since shortly following service discharge in 1998. The RO also found that the Veteran entered service with acne on her face but that such was permanently aggravated as a result of such service. It noted that upon discharge from service acne affected the face, chest, and back, and required recurrent medication for treatment. The Veteran's service-connected acne is rated under 38 C.F.R. § 4.118, Diagnostic Code 7806 (2012). By regulatory amendment effective August 30, 2002, substantive changes were made to the schedular criteria for evaluation of skin diseases, as set forth in 38 C.F.R. § 4.118, Diagnostic Codes 7800-7833; 67 Fed. Reg. 49596 -49599, July 31, 2002. Additional changes were made in October 23, 2008; however, the revised provisions are applicable only to claims received on or after October 23, 2008. Accordingly, because the Veteran's claim was received prior to that date, in April 1998, these revisions do not apply to the present case. 73 Fed. Reg. 54708 (Sept. 23. 2008). Accordingly, the Board will consider the claim under the pre- and post-2002 changes to the criteria for evaluating skin disorders. Under the former version of DC 7806, a 10 percent rating was warranted for eczema with exfoliation, exudation, or itching involving an exposed surface or extensive area. See 38 C.F.R. § 4.118, DC 7806 (2001). A 30 percent rating was assigned for eczema with constant exudation or itching, extensive lesions, or marked disfigurement. Id. To warrant a 50 percent rating, ulceration or extensive exfoliation or crusting, and systemic or nervous manifestation or exceptional repugnance needed to be shown. Id. According to the revised regulations, effective August 30, 2002, a 10 percent rating is warranted for dermatitis or eczema with at least 5 percent, but less than 20 percent, of the entire body or at least 5 percent, but less than 20 percent of exposed areas affected, or if intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks during the last 12-month period. A 30 percent rating is assigned for dermatitis or eczema with 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or if systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted with more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. 38 C.F.R. § 4.118, DC 7806 (2003). DC 7806 also allows for ratings under DCs 7800 through 7805. However, other than DC 7800, disfigurement of the head, face, or neck, the other DCs either apply to scars other than on the head, face, and neck, or do not provide for a rating higher than 10 percent. Under DC 7800, 10 percent rating is assigned for one characteristic of disfigurement; a 30 percent rating is provided when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or with two or three characteristics of disfigurement; a 50 percent rating is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or with four or five characteristics of disfigurement. Under Note (1), the 8 characteristics of disfigurement for purposes of evaluation under § 4.118 are: a scar 5 or more inches (13 or more cm.) in length; scar at least one-quarter inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation: scar adherent to underlying tissue; skin hypo-or hyper- pigmented in an area exceeding six square inches (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Under note (3) the adjudicator is to take into consideration unretouched color photographs when evaluating under these criteria. Under DC 7813, dermatophytosis is rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801-7805), or dermatitis (DC 7806), depending upon the predominant disability. During her initial VA examination in July 1998, the examiner reported that she had acne to the face, chest, and back that was being successfully treated with Retin-A, and Cleocin. The examination report did not describe any symptoms that are mentioned in the criteria for a 30 percent or greater rating. In addition, VA outpatient treatment records in the years following the examination focused on other service-connected and non-service-connected disabilities and did not yield findings showing a more severe disability picture. Rather, when her acne was examined in September 2007, the examiner noted that it had improved, that her face had almost no lesions, and only a couple lesions on the arms were unhealed. The diagnosis was hyperpigmented acne scars and well-controlled acne. Later, during a consultation in July 2008, acne was again described as "well-controlled." The Veteran reported that she was "happy" with the results of her treatment regimen, that her skin had cleared up, and that she had fewer breakouts. The consultations did not reveal evidence of any constant exudation or itching, extensive lesions, or marked disfigurement. While there was evidence of hyperpigmented scarring; there is no confirmation her acne caused any significant scarring or disfigurement. In addition, there is no evidence it has caused crusting or ulceration of the skin on her face. For the period prior to December 16, 2008, the existing 10 percent rating contemplates involvement of an exposed surface such as her face, with itching. As such, her symptoms are no more than 10 percent disabling under the former rating criteria. For the period prior to December 16, 2008, under the revised rating criteria for DC 7806, she would be entitled to the next higher rating of 30 percent if 20 to 40 percent of her entire body or exposed areas were affected. However, for this period the available evidence does not reflect that 20 to 40 percent of her body or exposed areas are affected by acne. The exposed areas affected are confined to the face. In addition, under DC 7806, a higher 30 percent rating is warranted if systemic therapy such as corticosteroids or other immunosuppressive drugs were required for 6 weeks or more during the past 12 months. Here, for the period prior to December 18, 2008, the record reflects that the Veteran was treated with Retin-A, tetracycline, and clindomycin. These medications are not corticosteroids or immunosuppresives and do not constitute "systemic therapy." The only other diagnostic code that could possibly warrant a higher 30 percent rating is DC 7800, which would require either tissue loss and gross distortion or asymmetry, or two or three characteristics of disfigurement. However, there is no evidence of tissue loss, gross distortion, or asymmetry, and there is no evidence the Veteran has more than one of the characteristics of disfigurement. The examinations, including color photographs, are unremarkable for a scar five or more inches in length or at least a quarter inch wide; and there is no evidence that the surface contour of any alleged scar is elevated or depressed on palpation; that any scar is adherent to the underlying tissue; that there is underlying soft tissue missing; or that the skin is indurated and inflexible. The only characteristic of disfigurement that may be applicable is abnormal skin texture in an area exceeding 6 square inches. However, even if this characteristic of disfigurement were present, it would be the only one, and one characteristic of disfigurement would not entitle the Veteran to a higher 30 percent rating. For these reasons, for the period prior to December 16, 2008, a schedular rating in excess of 10 percent is not warranted for the Veteran's acne. While the Veteran is in receipt of a 30 percent evaluation since December 16, 2008, the weight of the competent and probative evidence does not reveal a more disabling disability picture. For instance, symptoms typically associated with a higher rating, such as ulceration or extensive exfoliation or crusting, and systemic or nervous manifestation or exceptional repugnance are not shown. While the Veteran alleges that greater than 40 percent of the body is affected by acne, on VA examination in June 2009, the VA examiner concluded that less than 40 percent of the face and neck were affected. In addition, the June 2010 VA examiner also found no active acne lesions and described the extent of involvement on the face and neck as "none." Moreover, while she had multiple excoriations in different stages of healing; these were self-inflicted, and did not constitute acne. Rather, the June 2009 VA examiner referred to these as neurodermatitis and the June 2010 VA examiner specifically noted that "these are not acne." In adjudicating a claim the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what she observes or experiences; for example, she is competent to report that she experiences certain symptoms such as itching. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). However, despite her assertions regarding the extent of service-connected disability, the objective evidence does not show that 40 percent of his exposed areas of her body are affected by the acne. Therefore, when viewed collectively with the medical evidence of record, the Veteran's account of her symptomatology alone is not sufficiently credible to warrant a rating in excess of the assigned 30 percent evaluation for the period since December 16, 2008. C. Bilateral Knee Disability The Veteran seeks increased ratings for right and left knee patellofemoral syndrome with IT band tendonitis. By way of history, in a February 2001 decision, the RO granted service connection and assigned initial 10 percent evaluations for right knee and left knee patellofemoral syndrome, IT band tendonitis. Each knee disability was rated as 10 percent disabling. The current claims for increase were received in July 2008. The bilateral knee disabilities are rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5024. Under Diagnostic Code 5024, diseases are to be rated on limitation of motion of the affected parts, including degenerative arthritis but excluding gout. 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2012). Under Diagnostic Code 5010, traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (emphasis added). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion (emphasis added). When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent evaluation will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. The 10 and 20 percent evaluations based on X-ray evidence may not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. With any form of arthritis, painful motion is an important factor. It is the intention of the rating schedule to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. A compensable evaluation under Diagnostic Code 5003 and 38 C.F.R. § 4.59 (for painful motion) is in order where arthritis is established by X-ray findings and no actual limitation of motion of the affected joint is demonstrated. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Where compensable limitation of motion is demonstrated in the joint, the Lichtenfels rule is not applicable. The normal range of motion of the knee is to 0 degrees (full extension) to 140 degrees (full flexion). 38 C.F.R. § 4.71a, Plate II. When flexion of the knee is limited to 45 degrees, a 10 percent rating may be assigned. When flexion is limited to 30 degrees, a 20 percent evaluation may be assigned. A 30 percent rating may be assigned when flexion of the leg is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. When extension of the knee is limited to 10 degrees, a 10 percent evaluation may be assigned. When extension is limited to 15 degrees, a 20 percent evaluation may be assigned. When limited to 20 degrees, a 30 percent rating may be assigned. When extension is limited to 30 degrees, a 40 percent evaluation is assignable. A 50 percent evaluation may be assigned when extension of the leg is limited to 45 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. Slight recurrent subluxation or lateral instability warrants a 10 percent evaluation. A 20 percent rating requires moderate recurrent subluxation or lateral instability. A 30 percent rating requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain and effusion into the joint warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Removal of the semilunar cartilage which is symptomatic warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5259. VA General Counsel has held that a Veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. See VAOPGCPREC 23-97 (July 1, 1997; revised July 24, 1997). Moreover, in VAOPGCPREC 9-98, it was held that for a knee disability rated under Diagnostic Code 5257 to warrant a separate rating for arthritis based on x-ray findings and limitation of motion, the limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. Additionally, under VAOPGCPREC 9-2004 (September 17, 2004), a claimant who had both limitation of flexion and limitation of extension of the same leg must be rated separately under diagnostic codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. As such, if the evidence of record reflects compensable loss of both flexion and extension of the right leg, the veteran would be entitled to the combined evaluation under Diagnostic Codes 5260 and 5261, per the combined ratings table in 38 C.F.R. § 4.25. The Veteran underwent a VA examination in September 2008, two months after filing her claims for increase. The examination revealed findings of patellofemoral syndrome and mild degenerative arthritis of the knees. The examination revealed slightly limited range of motion. In particular, she could extend each knee to 0 degrees, and flex the right knee to 120 degrees and the left knee to 130 degrees. While there was pain at the end of motion, there was no loss of additional motion after three repetitions. Hence, a higher rating under Diagnostic Codes 5260 or 5261 is not for application. The examiner found that the knees did not lock or give away. As such, a higher evaluation under Diagnostic Code 5257 is not for application. There was no evidence of dislocated semilunar cartilage. As such, a higher rating under Diagnostic Code 5259 or 5259 is not warranted. Although there has not been loss or range of flexion or extension on examination, when assessing the severity of a musculoskeletal disability that, as here, is rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination - assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Here, the examiner noted a several month flare-up in 2007, but currently flare-ups occurred about once a month and lasted for days at a time. While an estimate of loss of range of motion due to flare-ups was not provided, the examiner noted that when a flare-up occurred in 2007, flexion was limited to 110 degrees. Flexion limited to 110 degrees would not result in a higher evaluation under Diagnostic Code 5270. The Board acknowledges the Veteran reports of bilateral knee pain, including pain with squatting, running, and when climbing stairs. The Court found that pain "may result in functional loss, but only if it limits the ability 'to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance.'" Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011) (quoting 38 C.F.R. § 4.40). The Court reiterated "that pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Id. at 43. Here, the VA examiner noted the reports of pain but found that the disability did not result in weakness, fatigability, lack of endurance, or incoordination. The examiner also noted that even with pain, she was able to get out of the house, walk, and do things as needed. Given these findings, and after consideration of all the evidence of record, the Board finds that pain does not equate to significant functional loss requiring the assignment of a higher disability rating. D. Sacroiliac Joints In a November 1998 decision, the RO granted service connection for degenerative changes to the sacroiliac joints and assigned an initial 10 percent rating. The current claim for increase was initiated in July 2008. The low back disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Diagnostic Code 5242 provides ratings for degenerative arthritis of the spine. Under Diagnostic Code 5003, degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint involved. However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is assigned with x-ray evidence of involvement of two or more major joints; a 20 percent rating is assigned with x-ray evidence of involvement of two or more major joints with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. The schedular criteria for the rating of spine disabilities evaluates degenerative arthritis of the spine (Diagnostic Code 5242) based on limitation of motion under the General Rating Formula for Disease and Injuries of the Spine. Under the General Formula, a 10 percent evaluation is warranted where disability results in forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A higher 20 percent evaluation is warranted where disability results in forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. A 40 percent evaluation is assigned for forward flexion of the thoracolumbar spine at 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. The General Formula for Diseases and Injuries of the Spine also, in pertinent part, provide the following Notes: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees; extension is zero to 30 degrees; left and right lateral flexion are zero to 30 degrees; and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The combined normal range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of the spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation; or neurological symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis). Id. Under the applicable criteria, intervertebral disc syndrome (preoperatively or postoperatively) is to be evaluated either under the general rating for disease and injuries of the spine (outlined above) or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Under Diagnostic Code 5243 (Intervertebral Disc Syndrome), a 10 percent evaluation is assigned with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A higher 20 percent evaluation is assigned with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent evaluation is assigned with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a maximum 60 percent evaluation is assigned with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. Diagnostic Code 5243 provides the following Notes: Note (1): An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment should be evaluated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. Id. After a review of all the evidence, lay and medical, the Board finds that, for the entire rating period, degenerative changes to the sacroiliac joints has been manifested by 80 degrees forward flexion in the thoracolumbar spine, extension from 0 to 40 degrees, lateral bending from 0 to 30 degrees, and rotation from 0 to 35 degrees. There was no change after three repetitions. There was tenderness in the upper gluteals and around L5 and spasms, but not guarding severe enough to result in an abnormal gait or abnormal spinal contour. With consideration of pain, the Board finds that the Veteran's disability meets the criteria for an 10 percent disability rating under Diagnostic Code 5003 but does not more nearly approximate for a 20 percent or higher rating. For the entire rating period, the Board finds that the Veteran has diagnosed degenerative changes to the sacroiliac joints which are manifested primarily by pain, which results in some limitation of motion of the thoracolumbar spine. A MRI dated in March 2006 revealed disc space narrowing, disc desiccation and minimal circumferential disc bulging at the L5-S1 level. The Board finds that the criteria for next higher 20 percent rating under Diagnostic Code 5242 have not been met or more nearly approximated for any portion of the rating period. Manifestations of degenerative changes to the sacroiliac joints have not more nearly approximated forward flexion of the thoracolumbar spine limited at 60 degrees or less, combined range of motion of the thoracolumbar spine limited at 120 degrees or less, guarding, or localized tenderness resulting in abnormal gait or abnormal spinal contour any time during the rating period. 38 C.F.R. § 4.71a. VA authorized examinations reflect 80 degrees flexion in the thoracolumbar spine. Pain did not result until flexion was to 85 degrees. Even with considerations of any additional limitation of motion due to pain, the Veteran's disability is not shown to approximate 60 degrees forward flexion or 120 degrees combined range of motion, and the Veteran's functional loss due to pain has already been considered in assigning the initial 10 percent evaluation under Diagnostic Code 5242. See 38 C.F.R. §§ 4.40, 4.45, 4.59, Deluca, 8 Vet. App. 202. The evidence also does not show guarding, or localized tenderness resulting in abnormal gait or abnormal spinal contour for any period of time to warrant a higher disability rating of 20 percent under Diagnostic Code 5242. The Board has considered whether a higher evaluation is warranted under Diagnostic Code 5243, which contemplates ratings for intervertebral disc syndrome based on incapacitating episodes. See 38 C.F.R. § 4.71a. For the entire rating period, the low back disability has not resulted in incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months to warrant a compensable evaluation under Diagnostic Code 5243. 38 C.F.R. § 4.71a. The Board has also considered whether a separate rating is warranted based on any neurologic manifestations the Veteran's lumbar spine disability. The General Rating Formula of Diseases and Injuries of the Spine allows for separate evaluations for chronic orthopedic and neurologic manifestations. 38 C.F.R. § 4.71a. The Board finds, however, that the Veteran does not have neurological manifestations due to her service-connected low back disability such as to warrant a compensable evaluation under the Diagnostic Codes for rating paralysis, neuritis, and neuralgia of the peripheral nerves. Here, during the September 2008 VA examination, while the Veteran reported pain radiating into the buttocks, there were no reports of pain radiating into the lower extremities. Moreover, she did not describe any bladder or bowel incontinence and on examination, straight leg raising was negative and no abnormal sensory findings were noted. VA outpatient treatment records also do not reveal evidence of a separately compensable neurologic disability. For instance, during treatment in June 2012, she specifically denied any pain radiating to the legs. In reaching the above conclusions, the Board has not overlooked the Veteran's statements with regard to the severity of her disability. In this regard, the Veteran is competent to report on factual matters of which she had firsthand knowledge, e.g., experiencing pain; and the Board finds that the Veteran's reports have been credible. The Board notes that during the Veteran's July 2008 VA examination, her lay statements were considered by the examiner. Even after consideration of such, however, the disability does not more nearly approximate the criteria for a 20 percent or greater disability evaluation. E. Additional Considerations The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected Epstein-Barr, acne, bilateral knee, and low back disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's residuals of Epstein-Barr virus, acne, bilateral knee, and low back disabilities with the established criteria shows that the rating criteria reasonably describe these disability levels and relevant symptomatology. Specifically, Epstein-Barr criteria consider the effects of fatigue and fibromyalgia pain; the acne criteria consider the extent of acne involvement to the extremities; and the knee and low back disability criteria specifically consider the reports of pain and limited motion. Thus, the current schedular ratings are adequate to fully compensate her for the disabilities on appeal. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. III. New and Material Evidence Claims The supplied service treatment records do not reveal findings of hypertension or uterine cysts. For instance, during a 5-day blood pressure check in 1996, blood pressure readings were as follows: 150/100, 148/92 on January 31, 1996, 138/94 on February 1, 1996, 120/90 on February 2, 1996, 111/92 and 127/77 on February 3, 1996, and 139/74 and 132/66 on February 4, 1996. On February 8, 1996, blood pressure was 133/84 and the examiner interpreted the results, noting that there was no hypertension and stated that blood pressure was "well controlled." (See service treatment records, packet 4 of 9.) Medical Evaluation Board proceedings in July 1996 included findings of degenerative arthritis, asthma, sinusitis, constipation, and a ganglion cyst, but did not include findings of hypertension or uterine cysts. (See service treatment records packet 7 of 9.) In April 1998, two months following her discharge from active duty, the Veteran filed a claim seeking service connection for uterine cysts and for hypertension. She underwent a VA examination in July 1998. She identified an in-service history of blood pressure that was "up and down." A physical examination, however, did not reveal elevated blood pressure or a diagnosis of hypertension. Rather, blood pressure was 108/70. No history was provided as to any uterine cysts, nor were any physical examination findings made documenting a current disability. In November 1998, the RO denied the claims. As it pertains to the claim for uterine cysts, the Veteran did not initiate an appeal. In addition, during the one-year period following the RO decision, no new and material evidence requiring readjudication of the claim. See Bond v. Shinseki, 659 F.3d 1362 (2011) (holding that VA must evaluate submissions received during the relevant period and determine whether they contain new evidence relevant to a pending claim, whether or not the relevant submission might otherwise support a new claim.). As such, the November 1998 decision is final. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 20.200, 20.202, 20.302, 20.1103. In November 1999, the Veteran filed a notice of disagreement that, in pertinent part, addressed the claim for hypertension. In addition, post-service outpatient treatment records for the period from May 1998 to February 1999 were submitted. They include isolated blood pressure readings. A January 1999 record noted increased blood pressure but did not include any readings. A February 1999 record noted blood pressure readings of 150/83 and 141/84. A statement of the case addressing the claim for service connection for hypertension was issued in December 1999. A substantive appeal was received in February 2000. In March 2000, she presented testimony during an RO hearing. She testified that she had elevated blood pressure during service but was not put on medication. She stated that she had a 5-day blood pressure study in service but reported that she had not been treated for hypertension since leaving service. (See Transcript at 16-17.) In February 2001, the RO reconsidered the claims for hypertension and for uterine cysts in light of the passage of the Veterans Claims Assistance Act of 2000 (VCAA). It again found that the service treatment records did not show findings of uterine cysts or for hypertension. It issued a supplemental statement of the case addressing the issues in February 2002. In February 2002, she was provided a Supplemental Statement of the Case (SSOC). She was informed that if she had filed a substantive appeal with respect to an issue addressed in the SSOC, then no further action was necessary. If, however, the SSOC addressed an issue not included in the substantive appeal, then she must file another substantive appeal for the new issue. In an October 2002 decision, the Board noted that the Veteran had not responded to the supplemental statement and therefore the issue of service connection for uterine cysts was not before the Board on appeal. Therefore, because the Veteran did not perfect an appeal of the February 2001 decision as it pertained to the claims for service connection for uterine cysts, that decision is final. The Board denied the claim for service connection for hypertension. The Veteran did not seek reconsideration of this decision or appeal to the Veterans Court. 38 U.S.C.A. §§ 7103, 7252 (West 2002); 38 C.F.R. § 20.1100 (2012). Thus, the Board's October 2002 decision may not be reopened and allowed on the same factual basis. See 38 U.S.C.A. §§ 5108, 7104. The current claims to reopen service connection for uterine cysts and hypertension were received in March 2007. The Board is required to determine whether new and material evidence has been received before it can reopen a claim and readjudicate service connection or other issues on the merits. See Barnett v. Brown, 83 F.3d 1380, 1383-1384 (Fed. Cir. 1996). In general, if new and material evidence is presented or secured with respect to a finally adjudicated claim, VA shall reopen and review the claim. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decisionmakers. 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 threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Evidence is presumed to be credible for the purpose of determining whether the case should be reopened; once the case is reopened, the presumption as to the credibility no longer applies. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence must be both new and material; if the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). If the Board determines that the evidence submitted is new and material, it must reopen the case and evaluate the appellant's claim in light of all the evidence. Justus, 3 Vet. App. at 512. Evidence submitted since the last final denial includes private and VA treatment records. Among the evidence are private treatment records that show that the Veteran was diagnosed in 2005 with intra uterine cysts. An August 2005 pelvic ultrasound described the condition as leiomyomatous changes of the uterus. In April 2006, she underwent a D.C. and hysteroscopy with a postoperative diagnosis of fibroid uterus and menometrorrhagia. In more recent records, she describes a history of "fibroids since '93" at which time she was told they were small, and was told she had three small fibroids in 1996. (See, e.g., VA outpatient treatment records dated in August 6, 2010, August 2, 2011.) In addition, private records dated in 2006 note a finding of hypertension. Here, the Board has considered this and other evidence added to the record since the last final denial. The Board finds that new and material evidence has been received and that the criteria to reopen the claims has been met. The claim for uterine cysts was previously denied because the evidence did not show uterine cysts in service or a current disability manifested by uterine cysts. The newly received evidence shows diagnoses for the condition. While the evidence does not show a diagnosis of fibroids until many years following service discharge, the Veteran has related to her physicians that the fibroid condition began in service in 1993. The Board must presume the credibility of such evidence for purposes of determining whether new and material evidence has been received. Similarly, the claim for hypertension was denied because the evidence did not show hypertension in service or a current disability manifested by hypertension. The newly received evidence shows hypertension. In addition, some of the treatment records in the first post-service year suggest but do not conclusively establish that she had symptoms of hypertension shortly following service discharge. While there remains no probative objective medical evidence indicating that current disabilities are be associated with her active military service, the lay evidence cited above triggers a duty on the part of VA to obtain a medical opinion. McLendon v. Nicholson, 20 Vet. App. 79 (2006) (which stipulates that the types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptoms such as pain or other symptoms capable of lay observation.) ORDER An increased initial rating for residuals of Epstein-Barr Syndrome, manifested by chronic fatigue syndrome and fibromyalgia, currently rated as 60 percent disabling, is denied. An increased initial rating for acne affecting the face, chest, and back, currently rated as 10 percent disabling since February 18, 1998, and 30 percent disabling since December 16, 2008, is denied. An increased rating for right knee patellofemoral syndrome with IT band tendonitis, currently rated as 10 percent disabling, is denied. An increased rating for left knee patellofemoral syndrome with IT band tendonitis, currently rated as 10 percent disabling is denied. An increased rating for degenerative changes sacroiliac joints, currently rated as 10 percent disabling is denied. The request to reopen the previously denied claim for service connection for uterine cysts is granted. The request to reopen the previously denied claim for service connection for hypertension is granted. REMAND The Board finds that the claim for service connection for a left foot skin disability must be remanded in order to afford the appellant a VA examination. In claiming service connection, she reported that she developed a left foot skin condition in October 1996 and was seen by a doctor in June 1997. She indicates that the skin condition was initially a blister but later resulted in a fungal condition. While the Board is unable to locate any service treatment record in June 1997 showing treatment for a left foot fungal condition, VA records do show treatment for a fungal infection to the foot in February 1999. Thus, there is documented clinical evidence showing treatment for a left foot fungal condition. What is unclear, however, is the nature and extent of any current left foot skin condition and its relationship, if any, to the Veteran's active military service. As to the reopened claim for service connection for uterine fibroids, the Veteran alleges treatment for such in service in 1993 and 1996. However, the service treatment records supplied by the Veteran do not show treatment for uterine fibroids. On remand, she should be asked to supply any records showing treatment for such condition. Then she should be afforded a VA examination to obtain an opinion as the etiology of uterine fibroids. As to the reopened claim for service connection for hypertension, the Veteran has submitted evidence showing a current diagnosis of hypertension. In addition, the medical evidence suggests that hypertension may have manifested to a degree of 10 percent within the first post-service year. Because the Board is precluded from making medical determinations in the first instance, this matter must be remanded to obtain a medical opinion. Accordingly, these matters are REMANDED for the following action: 1. Contact the Veteran and ask her to provide any evidence showing treatment for a left foot fungal condition, uterine cysts/fibroids, and hypertension, while in service, treatment of such since service, and any evidence discussing the etiology of any current left foot fungal condition, uterine cysts/fibroids, and hypertension disabilities. In particular, the Veteran's assistance is required in locating any record of treatment of a left foot fungal condition in June 1997, uterine cysts/fibroids in 1993 and 1996, and findings of hypertension in service or within the first post-service year. 2. Thereafter, the Veteran should be scheduled for a VA skin disorders examination. To the extent reasonably possible, the examination should be scheduled during a period of time when the skin disorder of the left foot is having a flare-up or an active phase. The claims file must be made available for review by the examiner. The examiner should comment as to the likelihood that any currently found skin disability of the left foot had its onset in service or is otherwise related to her active military service. The examiner should offer a fully supported explanation as to all opinions. In the event that the examiner concludes that an opinion cannot be offered without resorting to speculation, the examiner should fully explain the reason why the opinion cannot be offered. 3. Schedule the Veteran for an examination to obtain an opinion as to the likelihood that any currently found uterine cyst/fibroid disability is related to her active military service. The examiner should offer a fully supported explanation as to all opinions. In the event that the examiner concludes that an opinion cannot be offered without resorting to speculation, the examiner should fully explain the reason why the opinion cannot be offered. 4. Schedule the Veteran for a VA hypertension examination. Following a review of the relevant medical history and after examination, the examiner should render an opinion as to the likelihood that any currently hypertension disability is related to her active military service. The examiner should also provide an opinion as to whether the Veteran had hypertension in the first year following service discharge. The examiner should offer a fully supported explanation as to all opinions. In the event that the examiner concludes that an opinion cannot be offered without resorting to speculation, the examiner should fully explain the reason why the opinion cannot be offered. 5. The RO/AMC should review the examination report to determine if they are in compliance with this REMAND. If any of the reports is deficient in any manner, it should be returned to the physician, along with the claims file, for immediate corrective action. Where the remand orders of the Board or the Court are not complied with, the Board errs as a matter of law when it fails to ensure compliance, and further remand will be mandated. Stegall v. West, 11 Vet. App. 268 (1998). 6. Thereafter, the RO/AMC should readjudicate the appellant's claims for service connection for a left foot skin disorder, uterine cysts/fibroids, and hypertension. If the benefits sought on appeal remain denied, the appellant should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs