Citation Nr: 1329781 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 10-05 849 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an increased disability rating for service-connected status-post fracture of left fifth finger, boutonniere deformity with osteoarthritis, currently evaluated as 20 percent disabling. 2. Entitlement to service connection for carpal tunnel syndrome of the left wrist, claimed as secondary to service-connected left fifth finger disability. 3. Whether new and material evidence has been submitted to reopen claim of entitlement to service connection for an acquired psychiatric disorder to include depression and anxiety disorder. 4. Entitlement to a total disability rating claim based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Virginia Department of Veterans Services WITNESS AT HEARING ON APPEAL Veteran and Ms. J.A.L. ATTORNEY FOR THE BOARD K. K. Buckley, Counsel INTRODUCTION The Veteran served on active duty from June 1972 to August 1972 and had additional service in the Reserves, including a period of active duty for training from September 1979 to January 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which denied the Veteran's claims. In May 2012, the Veteran presented sworn testimony during a videoconference hearing, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's VA claims file. In September 2012 the Board remanded this case for further evidentiary development. As will be discussed below, review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The VA Appeals Management Center (AMC) continued the previous denials in an April 2013 supplemental statement of the case (SSOC) and the case has been returned to the Board for further appellate proceedings. In an October 2012 statement, the Veteran asserted his intent to file a claim under 38 U.S.C.A. § 1151 for nerve damage of the left foot, ankle, and calf due to surgery performed at the Salem VA medical center (VAMC) in 2010 on his hammer toe corrections. Accordingly, the issue of entitlement to compensation under 38 U.S.C.A. § 1151 has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). As will be detailed below, the issue of entitlement to service connection for an acquired psychiatric disorder is being reopened herein. The underlying issue of service connection as well as the claim of entitlement to TDIU are additionally addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC, in Washington, DC. The Veteran will be notified if further action on his part is required. Clarification of issue on appeal The RO has heretofore addressed the Veteran claims for service connection for an acquired psychiatric disorder including depression and entitlement to service connection for anxiety disorder separately. The Board observes that in addition to depressive disorder and anxiety disorder, the Veteran has been diagnosed with a variety of psychiatric disabilities including mood disorder, NOS, psychosis disorder, NOS, adjustment disorder, posttraumatic stress disorder (PTSD), and polysubstance abuse. It is clear that the Veteran is asserting entitlement to service connection for a psychiatric disability or disabilities, however diagnosed. The United States Court of Appeals for Veterans Claims (the Court) has decided that a veteran is not held to the disabilities (s)he has listed as a lay person without medical expertise; rather, service connection should be considered for any acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, (s)he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). The issue on appeal has been restated accordingly. FINDINGS OF FACT 1. The Veteran's service-connected status-post fracture of the left fifth finger, boutonniere deformity with osteoarthritis, is manifested by complaints of pain, limitation of motion, and functional impairment. The extent of disability is accurately reflected in the current maximum schedular rating assigned. 2. The Veteran's carpal tunnel syndrome of the left wrist was not caused or aggravated by his service-connected status-post fracture of left fifth finger, boutonniere deformity with osteoarthritis. 3. By an October 2006 decision, the RO denied the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder. 4. The evidence submitted since the October 2006 RO decision is neither cumulative nor redundant of the record at the time of the prior final denial of the claims of entitlement to service connection for an acquired psychiatric disorder, and is so significant that it must be considered in order to fairly decide the merits of the claim. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 20 percent for service-connected status-post fracture left fifth finger, boutonniere deformity with osteoarthritis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & West Supp. 2012); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5010, 5156 (2013). 2. Entitlement to service connection for carpal tunnel syndrome of the left wrist claimed as secondary to the service-connected left fifth finger disability is not warranted. 38 C.F.R. § 3.310 (2013). 3. An October 2006 RO decision denying a claim of service connection for an acquired psychiatric disorder is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1100 (2013). 4. Since the October 2006 RO decision, new and material evidence has been received with respect to the claim of entitlement to service connection for an acquired psychiatric disorder; this claim is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.129(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that claimant is expected to provide. Further, in Dingess v. Nicholson, 19 Vet. Ap. 473 (2006), the Court held that, upon receipt of an application for a service connection claim, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. See also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. Initially, with respect to the acquired psychiatric disorder claim, given the favorable action taken herein with regard to the issue of whether new and material evidence has been received sufficient to reopen the previously denied claim for service connection for an acquired psychiatric disorder, no further discussion of the VCAA requirements is required. Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49, 747 (1992). With regard to the increased disability rating claim, the law requires VA to notify the claimant that, to substantiate a claim, the claimant was must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing his or her entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular veteran's circumstances; that is, VA need not notify a veteran of the specific diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). As to the current appeal, letters dated in January 2009 and May 2009 complied with VA's duty to notify the Veteran with regard to the increased rating and service connection claim. In particular, the letters informed the Veteran of the need for evidence of a worsening of his service-connected disability. The letters also informed the Veteran of the evidence necessary to sustain a claim of entitlement to service connection to include on a secondary basis. Further, the Veteran was notified of the types of evidence that could substantiate his claims, such as medical records or lay statements regarding personal observations. He was asked to provide information as to where he had been treated and was informed that VA was responsible for obtaining any federal records, VA records, and any medical examinations, if necessary. In addition, the letters informed the Veteran that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. He was also specifically provided with notice of how disability ratings and effective dates are determined in the January 2009 and May 2009 letters. With respect to VA's duty to assist, the Veteran's service treatment records (STRs), Social Security Administration (SSA) records, VA vocational and rehabilitation file, and VA and private treatment records have been obtained and associated with the claims file. The Veteran was also afforded pertinent VA examinations in May 2011 and December 2012. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations obtained here are sufficient, as they considered all of the pertinent evidence of record, including the statements of the Veteran, and provided explanations for the opinions stated as well as the medical information necessary to apply the appropriate rating criteria. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2013). II. Increased rating claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, 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 general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the Veteran has been assigned a 20 percent disability rating for a service-connected left fifth finger disability throughout the appeal period. As will be detailed below, the Board finds that a staged rating is not warranted as to this claim. Here, service connection for status-post fracture of left fifth finger, boutonniere deformity with osteoarthritis, was established by a June 1995 rating decision, at which time a 10 percent rating was assigned, effective from February 16, 1995. In a March 2002 rating decision, the assigned evaluation was increased to 20 percent, effective from October 30, 2002. The Veteran is now seeking an increased rating. His service-connected status-post fracture of left fifth finger, boutonniere deformity with osteoarthritis, is currently rated as 20 percent disabled by analogy under 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5156 [arthritis, due to trauma, - little finger, amputation of]. See 38 C.F.R. § 4.20 (when an unlisted condition is encountered it will be permissible to rate it under a closely related disease or injury, in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous); see also 38 C.F.R. § 4.27(hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen). The Veteran claims entitlement to a higher evaluation for his status-post fracture of left fifth finger, boutonniere deformity with osteoarthritis. During his December 2012 VA examination, the Veteran reported that he suffers from pain, loss of motion, and weakness due to his service-connected left fifth finger disability. See the December 2012 VA examination report. The examiner documented the Veteran's report of flare-ups of pain. Loss of motion was documented, specifically a gap between the fingertip of the left little finger and the proximal transverse crease of the palm of less than one inch. The examiner reported functional loss/impairment with respect to the left fifth finger with less movement than normal documented. He also noted pain on movement and deformity as to the left fifth finger. The examiner specifically indicated that there was no evidence of ankylosis. The examiner noted that the Veteran is right hand dominant. The left fifth finger disability has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5156, which provides that a maximum 20 percent evaluation is warranted for amputation of the little finger with metacarpal resection (more than one-half the bone lost) of a minor extremity. The Board has considered whether any other applicable Diagnostic Codes could result in a higher rating; however, Diagnostic Code 5156 is the most appropriate rating to evaluate the Veteran's service-connected status-post fracture of the left fifth finger, boutonniere deformity with osteoarthritis. Critically, the evidence of record does not document amputation of any other finger, so a combination rating is not warranted for multiple finger amputation. Moreover, loss of use of the left hand has not been demonstrated by the record and as reported by the December 2012 VA examiner, ankylosis has not been demonstrated. Accordingly, the Veteran's service-connected left fifth finger disability has been assigned the maximum schedular rating available for this type of disability. As there is no legal basis upon which to award an increased schedular evaluation, the Veteran's appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The Board has also considered extraschedular evaluations concerning the appellant's service-connected disabilities presently on appeal. See Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992). Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extraschedular consideration referral). The schedular evaluation for the Veteran's status-post fracture of the left fifth finger, boutonniere's deformity with osteoarthritis, is not inadequate. The Veteran has filed many statements and testified that he believes that he should have a higher rating for pain, weakness, and loss of dexterity and strength in his left fifth finger. In this case, the Veteran's disability is rated under Diagnostic Codes that evaluate limitation of motion and amputation of the fifth finger. These Diagnostic Codes essentially take into account the pain and limitation of function reported in the record. As such, the schedule is adequate to evaluate the disability, and referral for consideration of an extraschedular rating is not warranted. Since the schedular evaluation contemplates the claimant's level of disability and symptomatology, the Board does not need to determine whether an exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. III. Service connection claim Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. § 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation; lay assertions of medical status do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Here, the Veteran contends that he has carpal tunnel syndrome of the left wrist secondary to his service-connected left fifth finger disability. See, e.g., the May 2012 Board hearing transcript. For the reasons set forth below, the Board concludes that service connection is not warranted. Initially, the Board notes that the Veteran has specifically raised the matter of his entitlement to service connection for carpal tunnel syndrome of the left wrist on a secondary basis. See the Veteran's claim dated January 2009 & the May 2012 Board hearing transcript. There is nothing in the Veteran's presentation, or elsewhere in the record, which leads the Board to believe that service connection on a direct basis is contemplated. See Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (holding that where a claimant has raised an issue of service connection, the evidence in the record must be reviewed to determine the scope of that claim. Claims which do not have support in the record need not be considered by the Board, however, as the Board is not obligated to consider "all possible" substantive theories of recovery. Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). Thus, the Board will consider the Veteran's claim on a secondary service connection basis alone and not on a direct service connection basis. Here, the Veteran asserts that he suffers from carpal tunnel syndrome of the left wrist that has been caused or aggravated by his service-connected left fifth finger disability. See the Veteran's claim dated January 2009 & the May 2012 Board hearing transcript. As will be explained below, the evidence does not support this contention. As indicated above, it is undisputed that the Veteran is currently service-connected for status-post fracture of the left fifth finger, boutonniere deformity with osteoarthritis. The Veteran was afforded a VA examination in May 2011 at which time he was diagnosed with carpal tunnel syndrome of the left wrist and ulnar compression at the left elbow. With respect to the question of medical nexus, the examiner concluded that "no, the currently diagnosed left carpal tunnel syndrome is not proximately due to or the result of the service connected disability of status-post fracture, left fifth finger, boutonniere deformity with osteoarthritis." He noted the Veteran's in-service injury to the left fifth finger. He continued, "[t]here is no evidence of in-service carpal tunnel. The two conditions are separate with no pathophysiologic connection between a longstanding little finger deformity and the compression of the medial and ulnar nerves in the wrist. The little finger is not innervated by the median nerve. The little finger is no[t] causing or associated with the cause of compression at this wrist." As to the question of aggravation, the examiner noted that "[t]he nerve conduction study reveals compression of the sensory components of the median and ulnar nerves along with significant ulnar compression to the elbow region. This compression at the elbow and wrist are the primary etiologies of the Veteran's symptoms and not related to the long standing deformity of the fifth left hand digit. There is no objective evidence of a neurologic deficit to the left hand caused by the deformity of the fifth finger." He therefore concluded, "it is this examiner's opinion the claimed disability of left carpal tunnel syndrome is not aggravated by the service-connected disability of status-post fracture, left fifth finger, boutonniere deformity with osteoarthritis." The Veteran was afforded another VA examination in December 2012 in order for the examiner to address the question of aggravation. With respect to the question of aggravation, the examiner noted that "[t]he Veteran's left fifth digit is innervated by the ulnar nerve. The Veteran's carpal tunnel condition is a median nerve condition. The Veteran has no functional impairments of the left wrist to aggravate the ulnar nerve innervating the left fifth digit." He continued, "[a]dditionally, the Veteran has severe left ulnar nerve palsy at the elbow (via NCS). Nerve function flows from the brain outward to the extremities. The Veteran today is trying to assert nerve function abnormalities originate from the left fifth digit upward to the elbow causing his symptoms of pain and numbness to the forearm. This is physiologically impossible." He concluded, "[t]he Veteran's carpal tunnel and ulnar condition of the left arm is etiologically tied to compression at the wrist and elbow and not the boutonniere deformity of the finger." The May 2011 and December 2012 VA medical opinions were based upon review of the record and analyses of the Veteran's entire history, including his medical history as to the service-connected left fifth finger disability. Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Moreover, the Veteran has not produced a medical opinion to contradict the conclusions set forth in the May 2011 and December 2012 VA examination reports. As was explained in the VCAA section above, the Veteran has been afforded ample opportunity to present competent medical evidence in support of his claim but has not done so. See 38 U.S.C.A. § 5107(a) (West 2002) (it is the claimant's responsibility to support a claim for VA benefits). Thus, the May 2011 and December 2012 VA medical opinions stand unchallenged as competent medical evidence on these crucial questions of medical nexus and aggravation. In this regard, the Board acknowledges that the Veteran has submitted his own statements to support his claim of service connection. As a lay person, the Veteran is competent to testify to observable symptoms such as pain and weakness. See Washington v. Nicholson, 21 Vet. App. 191, 195 (2007) (holding that, "[a]s a layperson, an appellant is competent to provide information regarding visible, or otherwise observable symptoms of disability); see also Barr, supra; Layno v. Brown, 6 Vet. App. 465 (1994). However, the Veteran is not competent to provide medical conclusions as to whether a disability is due to his left fifth finger disability. See Buchanan v. Nicholson, 451 F.3d 1331-37 (Fed. Cir. 2006); see also Miller v. Derwinski, 3 Vet. App. 201, 204 (1992). Therefore, to the extent that the Veteran claims that his carpal tunnel syndrome of the left wrist is caused or aggravated by his service-connected left fifth finger disability, laypersons without medical training, such as the Veteran, are not competent to comment on medical matters. See 38 C.F.R. § 3.159(a)(1) (2013). The Board further observes that the Veteran's contentions in support of dependent and/or aggravated symptomatology are contradicted by the findings of the VA examiner who specifically considered the Veteran's lay assertions and any such inferences contained in the record in rendering his negative nexus opinions in May 2011 and December 2012. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Therefore, the Board is unable to identify a reasonable basis for granting service connection. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). In summary, for the reasons expressed above, especially the uncontradicted medical opinion evidence, the Board concludes that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for carpal tunnel syndrome of the left wrist, as secondary to the service-connected status-post fracture of the left fifth finger, boutonniere's deformity with osteoarthritis. The benefit sought on appeal is accordingly denied. IV. Claim to reopen In the current appeal, the Veteran contends that his psychiatric disorder, to include depression and anxiety disorder, is due to his service-connected disabilities. In this regard, the Board notes review of the claims file reveals that service connection for a psychiatric disorder was denied by the RO in a decision dated in October 2006. The Veteran did not appeal and the decision became final. 38 U.S.C.A. §§ 7105 (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2013). As a result of the finality of the October 2006 decision, a claim of service connection for an acquired psychiatric disorder to include depression and anxiety disorder, may now be considered on the merits only if new and material evidence has been received. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); Evans v. Brown, 9 Vet. App. 273 (1996). The Board must consider the question of whether new and material evidence has been received because it goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim de novo. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no such evidence has been offered, that is where the analysis must end, and what the RO may have determined in that regard is irrelevant. Barnett, supra. Further analysis, beyond consideration of whether the evidence received is new and material, is neither required nor permitted. Id. at 1384; see also Butler v. Brown, 9 Vet. App. 167, 171 (1996). "New" evidence is evidence not previously submitted to agency decision makers. "Material" evidence is 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 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). In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). In this regard, the Board notes that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). When evaluating the materiality of newly submitted evidence, the focus must not be solely on whether the evidence remedies the principal reason for denial in the last prior decision; rather the determination of materiality should focus on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. Id. The relevant evidence of record at the time of the October 2006 RO decision consisted of STRs, private treatment records, VA treatment records, and the Veteran's statements. In the Veteran's claim dated March 2006, he asserted entitlement to service connection for depression as secondary to his service-connected left fifth finger disability. VA treatment records dated in January 2001 through May 2006 documented continuing diagnoses of adjustment disorder with depressed mood, major depressive disorder, and polysubstance abuse, as well as, possible PTSD secondary to a history of childhood abuse. Accordingly, at the time of the last final denial of the Veteran's service connection claim, there was insufficient evidence of a medical nexus between the Veteran's claimed acquired psychiatric disorder and his service-connected left fifth finger disability. Thus, the RO denied the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder. As indicated above, the Veteran did not appeal the RO's October 2006 decision, and the denial consequently became final. See 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1100. Relevant evidence received since the October 2006 decision consists of SSA records, VA and private treatment records, a June 2012 statement from Dr. M.B.D., and statements of the Veteran and his representative including the May 2012 Board hearing transcript. After a review of the entire record, the Board finds that additional evidence has been submitted that is sufficient to reopen the Veteran's claim. VA treatment records dated August 2008 to June 2013 document diagnoses of major depressive disorder, adjustment disorder, substance-induced mood disorder, generalized anxiety disorder, polysubstance abuse, and possible PTSD due to childhood abuse. Notably, an October 2011 VA treatment record documented the treatment provider's observation that the Veteran's pain "is a significant trigger for this patient's depression." Additionally, in a June 2012 letter, Dr. M.B.D. indicated that "it is at least as likely as not that [the Veteran's] substance abuse problems and depressive symptoms have some relation to his physical limitations, which have provided continual physical limitations, since his discharge from active duty in the U.S. Navy." Accordingly, pursuant to Shade, supra, evidence is new if it has not been previously submitted to agency decision makers and is material if, when considered with the evidence of record, it would at least trigger VA's duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. The October 2011 VA treatment record and the June 2012 letter from Dr. M.B.D., which suggest a medical nexus between the Veteran's currently diagnosed acquired psychiatric disorder and his service-connected physical disabilities, were not of record at the time of the last final denial. As such, this evidence is new. It is also "material" because it relates to unestablished facts necessary to substantiate the claim, namely the existence of medical nexus. The Board therefore finds that the newly submitted evidence meets the requirements of Shade for reopening. As a result, the Board finds that the newly added medical evidence, which is presumed credible, see Justus, supra, constitutes new and material evidence. Accordingly, the claim of service connection for an acquired psychiatric disorder, to include depression and anxiety disorder, is reopened with the submission of new and material evidence. See 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). ORDER Entitlement to an increased disability rating for service-connected status-post fracture of left fifth finger, boutonniere deformity with osteoarthritis, is denied. Entitlement to service connection for carpal tunnel syndrome of the left wrist is denied. New and material evidence sufficient to reopen a claim for service connection for an acquired psychiatric disorder, to include depression and anxiety disorder, has been received; to this limited extent, the appeal is granted. REMAND For the reasons expressed below, the Board finds that the underlying claims of service connection for an acquired psychiatric disorder must be remanded for further development. Additionally, the issue of entitlement to TDIU must also be remanded. With respect to the acquired psychiatric disorder claim, the Veteran contends that an acquired psychiatric disorder, to include depression and anxiety disorder, is proximately caused or aggravated by his service-connected disabilities. To this end, the Board notes that the Veteran is service-connected for status-post fracture of the left fifth finger, boutonniere deformity with osteoarthritis, as well as, right fifth metatarsal tailor's bunion status-post bunionectomies with screw fixation and left fifth metatarsal tailor's bunion status-post bunionectomies with screw fixation and hammertoe. As indicated above, in his June 2012 letter, Dr. M.B.D. provided a positive medical nexus opinion linking the Veteran's currently diagnosed substance abuse disorder and depressive symptoms with his service-connected disabilities. Significantly, Dr. M.B.D. did not provide any explanation to support his conclusion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (the failure of the physician to provide a basis for his/her opinion goes to the weight or credibility of the evidence). There are currently no other competent medical opinions of record which address the issue of medical nexus. The Board therefore concludes that an additional VA examination is necessary to address the currently diagnosed acquired psychiatric disability--including whether the acquired psychiatric disability was caused or aggravated by any service-connected disability. See Charles v. Principi, 16 Vet. App. 270 (2002); see also 38 C.F.R. § 3.159(c)(4) (2013) (a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim); see also Colvin v. Derwinski, 1 Vet. App. 191 (1999) (the Board is prohibited from exercising its own independent judgment to resolve medical questions). A remand for a new VA examination should therefore be accomplished in order to address these outstanding questions with respect to the Veteran's claimed acquired psychiatric disorder. Additionally, review of the record reflects ongoing VA medical treatment. Thus, on remand, any previously unobtained ongoing relevant medical records should be procured and associated with the Veteran's claims file. 38 U.S.C.A. § 5103A(c) (West 2002); Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if pertinent). The Veteran's claim of entitlement to TDIU is inextricably intertwined with the claim that currently remains on appeal. In other words, if service connection as to the issue is granted, this will impact VA's analysis of the TDIU claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). Therefore, the Board will defer consideration of the TDIU claim. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. After obtaining the appropriate releases where necessary, procure any records of outstanding treatment and/or evaluation that the Veteran has recently received. The Board is particularly interested in VA treatment records dating from June 2013. All such available documents should be associated with the claims file. 2. After the above-referenced development has been completed, VBA should schedule the Veteran for a VA psychiatric examination to determine the nature and etiology of his claimed acquired psychiatric disorder, to include depression and anxiety disorder. The claims file, including a copy of this remand, must be made available to the examiner for review in connection with the examination. All pertinent testing deemed necessary should be accomplished, and the results of any such studies should be included in the examination report. The examiner should identify each psychiatric disorder experienced by the Veteran or specifically rule out any such diagnosis. Any diagnostic testing deemed to be necessary by the examiner should be accomplished. For each psychiatric disability present, the examiner should indicate whether it is at least as likely as not (50 percent probability or more) that it had its clinical onset in service or is otherwise related to service or was caused or aggravated by his service-connected disabilities. If aggravated, specify the baseline of psychiatric disability prior to aggravation, and the permanent, measurable increase in psychiatric disability resulting from the aggravation. If the examiner determines that he/she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. 3. Thereafter, readjudicate the claims on appeal. If any benefit sought remains denied, the Veteran and his representative should be provided a supplemental statement of the case and given an opportunity to respond before the case is returned to the Board. No action is required of the veteran until he is notified by the RO; however, the veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2013). The Veteran 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs