Citation Nr: 1553978 Decision Date: 12/29/15 Archive Date: 01/07/16 DOCKET NO. 08-33 734 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a lumbar spine disability (previously degenerative joint disease of the lumbar spine). 2. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for bilateral refractive error (claimed as defective vision). 3. Entitlement to service connection for a lumbar spine disability. 4. Entitlement to service connection for obstructive sleep apnea. 5. Entitlement to service connection for bilateral eye disabilities (other than refractive error). 6. Entitlement to service connection for bilateral hip disorders. 7. Entitlement to service connection for a disability that manifests in the loss of feeling in the arms and legs. 8. Entitlement to service connection for traumatic arthritis (claimed as chronic arthritis), excluding claims associated with his lumbar spine, hips and ankle already on appeal. 9. Entitlement to an initial rating in excess of 20 percent for right ankle effusion with extensor group tendonitis. 10. Entitlement to a rating in excess of 30 percent for post-concussion migraine headaches. 11. Entitlement to a rating in excess of 10 percent for pseudofolliculitis barbae. 12. Entitlement to special monthly compensation based on the need for regular aid and attendance or being housebound. 13. Entitlement to a higher combined evaluation for the Veteran's service connected disabilities. REPRESENTATION Appellant represented by: Carl Pittman, Attorney ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel INTRODUCTION The Veteran served on active duty from July 1972 to September 1978. These issues come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In September 2015, the Veteran withdrew his request for a hearing before a member of the Board in writing. Claims of entitlement to service connection for posttraumatic stress disorder (PTSD), depression, dysthymic disorder, neurosis, bipolar disorder, and schizoaffective disorder, as well as entitlement to service connection for polysubstance abuse, were appealed to the Board. However, in a July 2014 rating decision, the RO granted entitlement to service connection for PTSD, and noted that this decision was considered a grant of all of the Veteran's psychiatric claims, as well as his claim for polysubstance abuse. Included in the ratings for the Veteran's grant of PTSD are period of temporary total rating based on hospitalization. Notably, these periods of hospitalization were substance abuse hospitalizations/rehabilitations. As such, the above listed conditions (psychiatric disorders, polysubstance abuse, and the claim for a temporary total rating from May to September 2006) are considered to have been satisfied by the grant of service connection for PTSD, and are no longer on appeal to the Board. The Veteran's claim for TDIU, which was appealed along with several other issues, was granted in a July 2014 rating decision. The grant of TDIU was provided from the day after his last day of work. As such, this is considered a full grant of the benefit on appeal, and the issue is no longer before the Board. The Veteran previously had a claim for entitlement to an earlier effective date than October 14, 2005 for the grant of service connection for post-concussion migraine headaches. This issue was addressed in an August 2011 Statement of the Case (SOC). However, in his October 2011 substantive appeal, the Veteran specifically did not appeal this issue. The issue(s) of entitlement to service connection for bilateral eye disabilities, bilateral hip disorders, a disability manifested by loss of feeling in the hands and feet, and a lumbar spine disability, as well as entitlement to increased ratings for headaches and right ankle effusion, and entitlement to SMC are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In a February 1979 rating decision, the VA denied the Veteran's claim for service connection for refractive error; the Veteran did not appeal this decision. 2. The evidence received since the February 1979 rating decision is cumulative or redundant of evidence previously of record, and does not raise a reasonable possibility of substantiating the claim of entitlement to service connection for bilateral refractive error. 3. In an April 1994 rating decision, the VA denied the Veteran's claim for service connection for a lumbar spine disability; the Veteran did not appeal this decision. 4. The evidence received since the April 1994 rating decision is not cumulative or redundant of evidence previously of record, and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a lumbar spine disability. 5. The preponderance of the evidence is against finding that the Veteran's obstructive sleep apnea was incurred in or is otherwise related to his military service. 6. The preponderance of the evidence is against finding that the Veteran has traumatic arthritis (excluding his lumbar spine, right ankle, and hips separately on appeal) that was incurred in or is otherwise related to his military service. 7. Prior to May 26, 2009, the Veteran's right ankle manifested in marked limitation of motion. He did not have ankylosis of the right ankle joint. 8. The combined evaluations of the Veteran's service-connected disabilities were properly calculated. CONCLUSIONS OF LAW 1. A February 1979 rating decision by the RO that denied the Veteran's claim for service connection for refractive error is final. 38 U.S.C.A. §§ 5108, 7105 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.156, 20.200 (2015). 2. New and material evidence has not been received to reopen the claim of service connection for refractive error. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. 3. An April 1994 rating decision by the RO that denied the Veteran's claim for service connection for a lumbar spine disability is final. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.200. 4. New and material evidence has not been received to reopen the claim of service connection for refractive error. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. 5. Entitlement to service connection for obstructive sleep apnea is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.309. 6. Entitlement to service connection for traumatic arthritis is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.309. 7. Prior to May 26, 2009, the criteria for rating in excess of 20 percent for the Veteran's right ankle disability have not been met. See 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5271. 8. The claim for a higher combined evaluation is without legal merit. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) provides that 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). 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). April 2011, January 2011, May 2009, December 2008, January 2007, December 2005, August 2005 and December 2002 letters fully satisfied the duty to notify provisions. The letters informed the Veteran of what evidence was required to substantiate the claims and of the Veteran's and VA's respective duties for obtaining evidence, as well as how VA determines disability ratings and effective dates. In Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court clarified VA's duty to notify in the context of claims to reopen. With respect to such claims, VA must both notify a claimant of the evidence and information that is necessary to reopen the claim and notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying claim for the benefit that is being sought. To satisfy this requirement, the Secretary is required to look at the bases for the denial in the prior decision and to provide the claimant with a notice letter that describes what evidence would be necessary to substantiate those elements required to establish service connection that were found insufficient in the previous denial. The Veteran was provided with Kent notice in the August 2005 letter. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA obtained the Veteran's service treatment records, VA medical records, and private and Social Security Administration (SSA) records. VA did not afford the Veteran an examination or obtain an etiological opinion for his traumatic arthritis claim. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. With respect to the third factor, the types of evidence that "indicate" that a current disorder "may be associated" with 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 symptomatology such as pain or other symptoms capable of lay observation. Id. Here, as will be discussed in greater detail below, there is no credible evidence of continuity of symptomatology or otherwise an indication provided which would indicate that a traumatic arthritis disability (excluding lumbar, hips and ankle disabilities separately on appeal) or related current symptoms may be associated with service. As such, the Veteran's claim for traumatic arthritis does not meet the low threshold requirements of McLendon, and the VA was not required to afford him a VA examination on that claim. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). Claims to Reopen Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. The Board notes in this regard that refractive error of the eye is not considered a disease or injury for VA disability compensation purposes. See 38 C.F.R. § 4.9. A finally adjudicated claim is an application which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is the earlier. 38 U.S.C.A. § 7105 (c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. Under the applicable provisions, new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with the 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). In Shade v. Shinseki, 24 Vet. App. 110 (2010), the Court clarified that the phrase "raises a reasonable possibility of substantiating the claim" is meant to create a low threshold that enables, rather than precludes, reopening. Specifically, the Court stated that reopening is required when the newly submitted evidence, combined with VA assistance and considered with the other evidence of record, raises a reasonable possibility of substantiating the claim. Id. The Veteran claims that he had defective vision (refractive error) and a lumbar spine disability as a result of his service, to include an in-service motor vehicle accident. In a February 1979 rating decision, the RO noted that the Veteran failed to appear for a VA eye examination, and as such the evidence was insufficient for rating purposes and that "jurisdiction over such is therefore not assumed by the Board. However, rating action is taken to show the refractive error noted at service enlistment is constitutional and developmental in nature and is not service-connected." The Veteran was informed of the denial of entitlement to service connection for refractive error on March 14, 1979; he did not appeal the decision, and the decision is final as to the evidence then of record. 38 U.S.C.A. § 7104; 38 C.F.R. § 20.1100. In an April 1994 rating decision, the RO denied entitlement to service connection for neck and back disabilities. The RO found that the Veteran did not receive treatment for his back in service, or at any time since service. There was additionally no evidence of a current disability. The Veteran was informed of the denial of entitlement to service connection for a lumbar spine disability on April 29, 1994; he did not appeal the decision, and the decision is final as to the evidence then of record. 38 U.S.C.A. § 7104; 38 C.F.R. § 20.1100. The Board notes that the Veteran's virtual file has had a very large number of documents added since the 1979 and 1994 denials, and therefore contains a large quantity of new evidence. Regarding the Veteran's refractive error claim, the record includes findings related to his refractive error as well as findings related to his other eye disorders, which are separately addressed in the REMAND section of this opinion. Prior to the February 1979 rating decision, the evidence of record was limited to the Veteran's service treatment records. Since the February 1979 rating decision, the Veteran has been afforded several VA eye examinations and has sought treatment for his vision on several occasions. In January 2003, the Veteran was afforded an eye examination where he was diagnosed with cataracts, pinguecula, presbyopia, and ametropia. A January 2005 record noted a gradual decrease in distance and near vision, unspecified cataracts, hypermetropia (farsightedness), astigmatism and presbyopia (farsightedness). In September 2008, he was diagnosed with presbyopia, cataracts, astigmatism, and hyperopia; dry eyes secondary to medication. In March 2012, the Veteran was noted to have nuclear sclerosis, cortical cataracts and dry eyes. His test results did not correlate with his subjective responses, suggesting hysteria or malingering. The examiner noted the Veteran had the same vision on entry and exit from service. A May 2012 examination found presbyopia (farsightedness), astigmatism, hyperopia (farsightedness). Although new evidence has been associated with the virtual record since the February 1979 rating decision, the new evidence is not material, as it does not raise a reasonable possibility of substantiating the Veteran's claim. 38 C.F.R. § 3.156(a). The Veteran's claim for service connection for refractive error was denied in 1979 because it is a congenital disorder. The new evidence of record continues to show that the Veteran has refractive error, and that he has other eye disabilities. The Veteran's additionally diagnosed eye disabilities are addressed in a separate claim. The 2012 VA examination additionally noted that the Veteran's vision remained the same at entrance and exit from service. The evidence continues to show refractive error, and refractive error is a congenital defect and is not a disease or injury in the meaning of applicable legislation for disability compensation purposes. As such, the additional diagnoses of refractive error do not raise a reasonable possibility of substantiating a service connection claim. As new and material evidence to reopen the previously denied claim of service connection for refractive error has not been received, the benefit-of-the-doubt doctrine is inapplicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). At the time of the April 1994 rating decision, the claims file contained the Veteran's service treatment records and some VA treatment records. Since that time the record has grown substantially. Included in the new evidence are ongoing complaints of low back pain, a diagnosis of questionable spondylosis of the lumbar spine in August 2006, a January 2007 diagnosis of transitional L5 vertebra with pseudarthrosis on the left and early degenerative joint disease, and a July 2009 diagnosis of lumbar spine spondylosis. The evidence added to the claims file after April 1994 is both new and material. The Veteran was previously denied entitlement to service connection for a lumbar spine disability because the evidence did not show treatment for spine symptoms or a spine diagnosis. The new evidence now includes a diagnosis of lumbar spondylosis. As this new evidence is material to the claim for service connection for a lumbar spine disability, the Board concludes that sufficient evidence has been submitted to reopen the claim. 38 C.F.R. § 3.156(a). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) . An alternative method of establishing the second and third elements of service connection for those disabilities identified as a "chronic condition" under 38 C.F.R. § 3.309(a) is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A claimant can establish continuity of symptomatology with competent evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between a current disability and the post-service symptomatology. 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has recently held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Obstructive sleep apnea is not recognized as chronic disease under 38 C.F.R. § 3.309, and thus the theory of continuity of symptomatology cannot be used as an alternative method of establishing the second and third elements of service connection. Arthritis is recognized as a chronic disease under 38 C.F.R. § 3.309. Sleep Apnea In August 2006, the Veteran filed a claim for service connection for several issues, including chronic sleep apnea. Service treatment records do not contain a diagnosis of obstructive sleep apnea. However, in February 1977, the Veteran reported "problems sleeping for the past few days." When questioned, the Veteran denied "emotional problems." No diagnosis was provided at the time. The Veteran is currently service-connected for PTSD. A September 2005 psychiatric treatment record included the Veteran's report of "tiredness, partially due to sleep loss secondary to nightmares and partially due to heavy demands at his job." A June 2006 dentistry treatment record noted the Veteran had a history of traumatic brain injury (for which the Veteran is service-connected), and he would "awaken anoxic." He was referred to a physician to rule out sleep apnea. During a pulmonary consultation, he also reported shortness of breath at night, snoring, and feeling tired during the day, and headaches. The physician suggested he be fitted for a CPAP based on these symptoms, and ordered a sleep study. In August 2006, the Veteran asked if his sleep problems were related to his prior auto accident. The VA physician "advised in clear terms that [s/he] did not see him for an auto accident, he was seen as per referral from his mental health counselor." In July 2009, the Veteran was afforded a VA general medical examination. He reported that after his in-service motor vehicle accident (1973), he had increased problems with snoring and gasping for breath at night. He reported in 2006 he was diagnosed with sleep apnea via a sleep study. Functionally, he reported he was not sleeping better on a CPAP, and he continued to cough at night and have frequent awakenings, as well as daytime fatigue. The examination did not include a medical nexus opinion. In March 2012, the Veteran was afforded a VA sleep apnea examination. He reported he had been using a CPAP for 4-5 years. He stated his belief that he developed sleep apnea as a result of the facial trauma he underwent in service after going through the windshield during a motor vehicle accident in 1973. He reported he was a "long-term snorer." He stated he was unsure when his snoring started. He also reported long-term problems with tiredness "over the last several years." A sleep study was performed in June 2006 and diagnosed sleep apnea. The examiner opined that it was less likely than not that the Veteran's sleep apnea was caused by his service. The examiner found that there was no medical evidence linking the Veteran's sleep apnea to his military service. Although the Veteran had some facial trauma with his in-service motor vehicle accident, the examiner noted that it was dental and soft tissue trauma without facial fracture. On physical exam, the Veteran had classic oropharyngeal findings which predisposed him to sleep apnea (a large tongue and long soft palate). "His development of sleep apnea is considered a 'life event' and was not influenced by an in-service injury or trauma while on active duty. There is also not any provable link that the Veteran's sleep apnea was incurred in active duty as snoring, as a symptom, does not diagnose sleep apnea. Regardless of his military service, this Veteran was predisposed to develop sleep apnea based on his body make up." 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 also has a duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Board acknowledges that the Veteran is competent to give evidence about what he experiences. See Layno v. Brown, 6 Vet. App. 465 (1994). Competency of evidence, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). See also Buchanan, supra (The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. If the Board concludes that the lay evidence presented by a veteran is credible and ultimately competent, the lack of contemporaneous medical evidence should not be an absolute bar to the veteran's ability to prove his claim of entitlement to disability benefits based on that competent lay evidence.) Initially, the Board notes that the Veteran is competent to report symptoms such as snoring, tiredness, and shortness of breath; however, he is not competent to diagnose obstructive sleep apnea or to associate his symptoms of sleep loss and snoring to a diagnosis of sleep apnea 28 years after discharge from service. Similarly, he is not competent to relate his diagnosis of sleep apnea to his in-service motor vehicle accident. Additionally, during the 2012 examination the Veteran indicated that he was not sure when he started snoring. When reporting his sleep disturbance in service, the in-service medical treatment provider questioned the relationship between his sleep loss and his emotional state, and did not indicate the possibility of sleep apnea. Treatment records prior to 2006 included statements from the Veteran that he was not sleeping well due to nightmares and increased work stress. Lastly, the Veteran is questionably a credible source of information, to include when reported symptoms began, due to discrepancies in his record. He has been noted by eye examiners and audiologists to have objective testing that did not match the Veteran's subjective complaints, and to be questionably malingering. He also reported to a VA treatment provider that he had a brain tumor diagnosed by MRI, which is not found in the record, and during psychiatric treatment has reported that he lost consciousness for five hours after his in-service accident, was pronounced dead, and that he woke up in the morgue. This story is not supported by his in-service treatment records. Accordingly, the Veteran's statement that he experienced snoring in service following his accident, and that this symptom in service represented sleep apnea, is not competent or credible evidence. 38 C.F.R. § 3.159(a). The medical evidence of record shows that the Veteran was diagnosed with obstructive sleep apnea in 2006, 28 years after his discharge from service and 33 years after his in-service motor vehicle accident. Additionally, the 2012 VA examiner found that the Veteran's sleep apnea was less likely than not related to his service, to include his in-service accident, because the accident only resulted in soft tissue and dental trauma, and not in facial fracture. The examiner found that the Veteran's sleep apnea was a result of his large tongue and a long soft palate, and that these were simply part of his body make-up. The record does not contain any conflicting medical opinions. Given the above, the Board finds that the weight of the evidence is against finding a link between current sleep apnea and service. As such reasonable doubt does not arise and the claim is denied. 38 U.S.C.A. § 5107(b). Traumatic Arthritis In February 2005, the Veteran reported that he had back and neck pain due to his in-service accident. He then noted that he was losing feeling in his arms and legs regularly, and "arthritis is now setting in." In October 2005, the Veteran noted that he had "arthritis that is related to his auto accident in 1973." He stated that "my arthritis was not present then, but has set up an traumatic arthritis over time." In a June 2006 rating decision, the Veteran's claim for service connection for traumatic arthritis was denied. Additionally, claims to reopen claims of service connection for a cervical spine disability and a lumbar spine disability, as well as a claim for service connection for loss of feeling in the arms and legs were also denied. In August 2006, the Veteran provided a statement asking to open claims for service connection for numerous issues including "back, neck, arms, legs, hips, chronic arthritis, sleep apnea, defective vision, migraine headache." Following the submission of additional evidence, the RO continued the denial of traumatic arthritis in an August 2007 rating decision. This rating decision also denied hip disorders, loss of feeling in the arms and legs, to reopen a claim for lumbar spine disorder. On his September 2007 notice of disagreement, the Veteran disagreed with the denials related to his sleep apnea, hip disorders, PTSD, arthritis, loss of feeling, degenerative joint disease of the spine, refractive error, and bipolar disorder. The Veteran did not continue a claim to reopen his neck claim after the June 2006 denial. In October 2008, the Veteran submitted a substantive appeal of several issues, including "degenerative arthritis" and "arthritis," as well as loss of feeling of the legs and arms. The RO interpreted his "degenerative arthritis" appeal to refer to his lumbar spine. Initially, the Board notes that the Veteran has not made any statements to further clarify what he meant by a claim for service connection for "traumatic arthritis." The Veteran has claims for service connection for a lumbar spine disability, bilateral hip disabilities, a disability manifested by loss of feeling in the arms and legs, and an increased rating for a right ankle disability pending separately from this claim for traumatic arthritis. Additionally, the Veteran abandoned a claim to reopen a claim of entitlement to service connection for a cervical spine disability. In August 2006, the Veteran reported "chronic low back pain and bilateral knee pain since 1973." However, the history then notes that he has had back pain since the accident in 1973, and that the pain radiates to his lower extremities. The impression was of chronic low back pain and probably lumbar spondylosis. During a March 2007 report of history and physical, the Veteran complained of blurry vision, pain, numbness and stiffness of the extremities after walking three to four blocks, and occasional swelling of the ankles. He reported pain in "almost all his joints, except his elbows" for the "past several years." He reported low back, neck, knees, hips, wrists, hands and shoulder pain "for the past several years." He reported tiredness and headaches since an in-service motor vehicle accident. On physical evaluation he had "reasonable range of movement of all extremity joints" with some crepitus of his neck. He was assessed with "osteoarthritis involving nearly all his extremity joints," and he was told to take Motrin to control the pain. Here, although the 2007 physician diagnosed ostearthritis of all joints, the record does not contain evidence of a diagnosis of arthritis by x-ray of any joints other than the Veteran's lumbar spine As noted above, the Veteran is questionably credible in reporting his history of symptom onset. Here, he would be competent to report on the onset of pain and the continuation of pain from service to the present. However, the record contains statements that his lumbar spine, which is separately on appeal, has been painful since service. There is an indication that his knees have been painful since the motor vehicle accident, except the second sentence is that his back has been painful since the accident, and his pain radiates from his back down his legs. In 2007, the Veteran reported that the pain in all of his extremity joints began within the past several years, which does not indicate a history of pain beginning 34 years prior. VA did not afford the Veteran a VA examination for this claim. The Veteran had an in-service motor vehicle accident. In service he complained of headaches and had lacerations to his face. He did not complain of joint or back pain. In subsequent statements he has indicated that he has chronic low back pain since the accident, and he has filed claims for a disability manifested by loss of feeling in his arms and legs, a bilateral hip condition, and he has a service-connected right ankle disability. In 2007, he stated that his joint pain began in the "past several years," and did not allege that the joint pain began in service. He has not alleged a continuation of symptoms which may provide an indication that the disability or persistent or recurrent symptoms of a disability may be associated with his service. Medical records do not contain a diagnosis of traumatic arthritis. The symptoms the Veteran has complained of-numbness and pain in the joints of the arms and legs, are associated with other claims on appeal. In sum, the medical evidence of record does not include a diagnosis of traumatic arthritis, there is no continuation of symptoms from service to the present (that are not a part of the separately addressed claims-specifically low back disability), and there is no medical evidence indicating a link between a current disability and service. Given the above, the Board finds that the weight of the evidence is against finding a link between "traumatic arthritis" and service. As such reasonable doubt does not arise and the claim is denied. 38 U.S.C.A. § 5107(b). Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The Schedule is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. When two evaluations are potentially applicable, VA will assign the higher evaluation when the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. VA will resolve reasonable doubt as to the degree of disability in favor of the Veteran. 38 C.F.R. § 4.1. If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). As a result, a complete medical history of the Veteran is required for a ratings evaluation. This is in order to protect claimants against adverse decisions based on a single, incomplete, or inaccurate report, and to enable VA to make a more precise evaluation. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, VA has a duty to acknowledge and consider all regulations which are potentially applicable, and to explain the reasons and bases for its conclusions. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id.; see also 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. Consideration of a higher rating for functional loss, to include during flare ups, due to these factors accordingly is warranted for Diagnostic Codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain itself does not constitute functional loss, and painful motion does not constitute limited motion for the purposes of rating under Diagnostic Codes pertaining to limitation of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain indeed must affect the ability to perform normal working movements with normal excursion, strength, speed, coordination, or endurance in order to constitute functional loss. Id. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Hart v. Nicholson, 21 Vet. App. 505, 509 (2007). Separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59 (2014). Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The Veteran's service-connected right ankle disability is currently provided a 20 percent rating under Diagnostic Code 5271, effective February 13, 1984. As the rating has been in effect for more than 20 years, it is now protected. Under this diagnostic code, a 10 percent rating is warranted for moderate limitation of ankle motion, and a 20 percent rating is warranted for marked limitation of motion. Further, under appropriate VA regulations, full range of ankle dorsiflexion is from zero to 20 degrees, and full range of ankle plantar flexion is from zero to 45 degrees. 38 C.F.R. § 4.71, Plate II. The descriptive terms "moderate" and "marked" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for an "equitable and just" decision. 38 C.F.R. § 4.6. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Diagnostic Code 5270 provides a 20 percent rating for ankylosis of the ankle in plantar flexion, less than 30 degrees. A 30 percent is provided for ankylosis in plantar flexion, between 30 and 40 degrees, or in dorsiflexion between zero and 10 degrees. A 40 percent rating is provided for ankylosis in plantar flexion at more than 40 degrees or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. The other ankle diagnostic codes do not include ratings in excess of 20 percent. Diagnostic Code 5262 provides a 30 percent rating for malunion of the tibia and fibula with marked knee or ankle disability, and a 40 percent rating for nonunion of the tibia and fibula with loose motion, requiring a brace. A May 2006 record noted that the Veteran used a "stick cane" to prevent falls when his legs go numb. He noted bike riding and walking helped to decrease stiffness. During an August 2008 physical therapy session the Veteran's range of motion and strength testing was noted to be unreliable. The Veteran complained of low back pain on use of his upper extremities, and said he could not raise his arms because it hurt his back. He also indicated he could not dorsiflex his ankles, "although he is able to heel strike during ambulation." In May 2009, the Veteran was afforded a VA joints examination. He reported right ankle sprain and effusion in 1973 with repetitive injuries to the ankle over time. He reported he had surgery to relieve persistent effusion. He reported near-constant pain on weightbearing that goes across the top of the foot. He often loosens his shoe or wears them untied to relieve pressure and pain on the top of his foot. A high-topped shoe was utilized for stability as well as dependence on a cane. He reported feeling he was "losing flexibility" in the foot. He described symptoms of giving way, instability, pain, stiffness, weakness, decreased speed of joint motion, constant effusions, and several episodes of locking (less than monthly). There were no constitutional symptoms of arthritis, and no incapacitation episodes of arthritis. On physical examination the Veteran had an antalgic gait with poor propulsion and evidence of abnormal weight-bearing through callus formation, fungal infection and an abnormal shoe-wear pattern. The examiner noted a historic "chip" fracture on x-ray. The examiner found the ankle to have instability with a "tendency to inversion with weakness of the extensors." The tendon abnormality was laxity in the tibialis extensors with swelling and tenderness. He had right dorsiflexion from zero to 10 degrees, and plantar flexion from zero to 20 degrees. He was unable to test repetitive range of motion due to pain and guarding. The examiner noted "laxity on passive manipulation with guarding." There was no joint ankylosis. A May 2009 x-ray showed no significant osseous, articular or soft tissue abnormality. The impression was "normal...no evidence of fracture or degenerative joint disease is detected." The examiner noted that the sprain of the top of the foot to the medial malleolus and chronic pattern of extensor instability and localized pain and swelling was at the top of the ankle joint articulation, and he had chronic inflammation. Based on the May 2009 VA examination, the Veteran had half of the normal range of motion of dorsiflexion, and 25 degrees less than the normal range of motion of plantar flexion. Additionally, the Veteran did not participate in repetitive testing due to pain. The examiner noted objective laxity in the right ankle. The Veteran's loss of range of motion of the right ankle remains marked. The examiner noted that the Veteran does not have ankylosis of the joint, and as such, ratings under DC 5270 are not applicable. Additionally, the May 2009 x-ray did not show malunion or nonunion of the tibia and fibula, and as such ratings under 5262 are not applicable. As such, the Veteran currently has the highest rating available for limited motion of the ankle, and a higher rating under an alternative diagnostic code is not warranted. The Board notes that there is a diagnostic code for other injuries of the foot, which provides a 30 percent rating for severe injuries of the foot. However, the VA examiner and the VA physical therapist have indicated that the Veteran's disability is in his ankle, and therefore, a jump to a foot disability rating is not appropriate. Therefore, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran's right ankle disability. The Board has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis for all conditions currently on appeal. 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). The Board is remanding the claim for a rating in excess of 20 percent for a right ankle disability from May 26, 2009 because of the lack of evidence in the claims file from that date, which is now more than six years old. According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (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 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 of the right ankle that the available schedular evaluation is inadequate. A comparison between the level of severity and symptomatology of the Veteran's right ankle condition with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. These include functional limitation as a result of limitations from range of motion and additional factors such as pain, fatigue, weakness, lack of endurance, or incoordination. The Board considered additional diagnostic codes related to the ankle to determine if a higher evaluation could be found under a different rating; however, the Veteran's symptoms and disability level did not meet the higher ratings considered by the Board. Thus, the Veteran's current ratings are adequate. 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. The Veteran is already in receipt of total disability based on individual unemployability (TDIU). Combined Rating The Veteran contends that a higher rating is warranted for his service connected disabilities. Although the Veteran initially appealed the calculation of his combined ratings when his combined ratings were listed as 80 percent, and these ratings have now changed, the Board will still address his contention regarding the total combined rating for his disabilities. The Veteran contends that his disabilities have been improperly combined. Calculating the proper combined evaluation requires the use of 38 C.F.R. § 4.25 and the Combined Ratings Table. 38 C.F.R. § 4.25. The Veteran was issued a copy of the Combined Ratings Table in several of the statement of the cases on file. Table I, Combined Ratings Table, results from the consideration of the efficiency of the individual as affected first by the most disabling condition, then by the less disabling condition, then by other less disabling conditions, if any, in the order of severity. To use Table I, the disabilities are arranged in the exact order of their severity, beginning with the greatest disability and then combined with use of Table I. For example, if there are two disabilities, the degree of one disability will be read in the left column and the degree of the other in the top row, whichever is appropriate. The figures appearing in the space where the column and row intersect will represent the combined value of the two. This combined value will then be converted to the nearest number divisible by 10, and combined values ending in 5 will be adjusted upward. Thus, as an example, for a 50 percent disability and a 30 percent disability, the combined value will be found to be 65 percent, but the 65 percent must be converted to 70 percent to represent the final degree of disability. If there are more than two disabilities, the disabilities will also be arranged in the exact order of their severity and the combined value for the first two will be found as previously described for two disabilities. The combined value, exactly as found in Table I, will be combined with the degree of the third disability (in order of severity). The combined value for the three disabilities will be found in the space where the column and row intersect, and if there are only three disabilities will be converted to the nearest degree divisible by 10, adjusting final 5's upward. Thus, for example, if there are three disabilities ratable at 60 percent, 40 percent, and 20 percent, respectively, the combined value for the first two will be found opposite 60 and under 40 and is 76 percent. This 76 will be combined with 20 and the combined value for the three is 81 percent. This combined value will be converted to the nearest degree divisible by 10 which is 80 percent. The same procedure will be employed when there are four or more disabilities. 38 C.F.R. § 4.25. Further, the application of the bilateral factor contained in 38 C.F.R. § 4.26 provides that, when a partial disability results from disease or injury of both arms, or of both legs, or of paired skeletal muscles, the ratings for the disabilities of the right and left sides will be combined as usual, and 10 percent of this value will be added (i.e., not combined) before proceeding with further combinations, or converting to the degree of disability. In this case, the Veteran contended that his service-connected disabilities should yield a higher evaluation as of August 24, 2006. At the time of the appeal, the Veteran was rated a combined 80 percent, effective August 24, 2006. The evaluations have changed since he started the appeal, and the Board will address his current evaluations. Currently, the Veteran is service connected for PTSD (with staged ratings of 100 percent from May 16, 2006, 50 percent from October 1, 2006, 100 percent from March 6, 2007, and 50 percent from May 1, 2007), bilateral hearing loss (40 percent from August 24, 2006), traumatic brain injury (10 percent from November 20, 2002, and 40 percent from July 26, 2012), migraines (30 percent from October 14, 2005), right ankle disability (20 percent from February 13, 1984), skin disorder (10 percent from November 20, 2002), and tinnitus (10 percent from July 1, 2002). The Board has calculated the Veteran's combined evaluation by applying the Combined Ratings Table of 38 C.F.R. § 4.25 to his compensable service-connected disabilities from October 1, 2006, as follows: the Veteran's 50 percent PTSD disability and 40 percent hearing loss would combine to 70 percent. This combines with the Veteran's 30 percent headaches to 79 percent. The 79 percent combines with the 20 percent ankle to 83 percent. The 83 percent combines with 10 percent tinnitus to 85 percent. The 85 percent combines with 10 percent skin disorder to 87 percent. The 87 percent rating with 10 percent brain injury combines to 88 percent. This number would round up and warrant a combined 90 percent rating from October 1, 2006. Although the Veteran appealed the rating from August 24, 2006, a temporary total rating meant that the Veteran had a 100 percent rating from May 16, 2006 to October 1, 2006. Additionally, the 50 percent PTSD combined with 40 percent hearing loss would equal 70 percent. The 70 percent combined with 40 percent brain injury (effective July 26, 2012), would equal 82 percent. The 82 percent rating combined with the 30 percent migraines would equal 87 percent. The 87 percent combined with 20 percent ankle would equal 90 percent. The 90 percent combined with 10 percent tinnitus would equal 91 percent. The 91 percent combined with the 10 percent skin disorder would equal 92 percent. This number would round down to 90 percent. The May 2015 rating code properly includes the combined 90 percent rating from October 1, 2006, with a period of temporary 100 percent from March 6, 2007 to May 1, 2007. The combined rating is not a simple matter of addition and the Board is compelled to apply the regulation. As the RO's calculation of the combined evaluation is in accordance with 38 C.F.R. §§ 4.25 and 4.26, there is no legal basis for a higher combined evaluation by operation of law. Where the law and not the evidence is dispositive, the claim must be denied because of lack of legal entitlement under the law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). ORDER New and material not having been submitted, the request to reopen the claim for service connection for refractive error is denied. New and material evidence having been received, the claim to reopen a claim for service connection for a lumbar spine disability is granted. Entitlement to service connection for obstructive sleep apnea is denied. Entitlement to service connection for traumatic arthritis is denied. For the period prior to May 26, 2009, entitlement to a rating in excess of 20 percent for a right ankle disability is denied. Entitlement to a higher combined evaluation for the Veteran's service connected disabilities is denied. REMAND The Board regrets that a remand is warranted in this case; however, additional development is required. The large virtual record contains few records from 2009 to the present. On remand, ongoing VA treatment records should be added to the record. Eyes In March 2012, the Veteran was afforded a VA eye examination and he was found to have nuclear sclerosis, cortical cataracts, and dry eyes. He stated he believed his poor eye sight was a result of his in-service motor vehicle accident with left eye laceration. The examiner found that the "physical findings do not correlate with the subjective responses of the patient. On one test he had a total black visual field test and on a retest he had only central vision just over 20 degrees. This suggests hysteria or malingering." The examiner noted the records showed the same vision entry into military and on exit he had the same vision. A large cortical cataract was noted in the left eye from the records, but "because the vision in the military service records were the same on entry as on exit the cataract left eye is less likely than not caused by or as a result of the blow to the left side of the face." In May 2012, the Veteran was afforded a VA eye examination. The examiner noted the Veteran was in a questionable mental state as during the examination the Veteran reported the letters kept "jumping around and changing." He was diagnosed with cataracts, but the examiner noted that he had "hysterical-type visual fields-they contradict each other." The Veteran's responses were too inconsistent to the same test. He was diagnosed with presbyopia, astigmatism, hypertropia and cataracts. The examiner stated that he could not resolve the nexus issue without resort to mere speculation; however, it was not clear why the examiner could not resolve the nexus issue. If it was in relation to the Veteran's mental state or another factor. A September 1973 service treatment record noted that his left eye showed either an extremely small "estoped or ? fixation" (difficult handwriting). A November 1973 record noted a negative cornea under slit lamp, but a subconjunctival hemorrhage. It was noted that the Veteran would heal in time. A February 1975 record noted that the slit lamp was of a poor view. The veteran reported several injuries to his eyes. The treatment provider noted lenticular opacity in the left eye, possibly secondary to trauma. The 2012 examinations did not take into account the Veteran's in service treatment records noting a laceration to his left eyelid, an opacity in his left eye, and a subconjunctival hemorrhage. Additionally, the May 2012 examiner found that he was unable to provide a nexus opinion without resorting to speculation, but did not provide an explanation as to what elements were missing to make a nexus opinion, or if it was simply a result of the Veteran's mental state. On remand, the RO should again attempt to have an eye examination and nexus opinion. Ankle, Headaches and Pseudofolliculitis Barbae The most recent examination of the Veteran's right ankle occurred in May 2009. As this examination is more than six years old, and the Veteran has continued to indicate that he deserves an increased rating for his right ankle disability, an updated examination should be provided on remand. Regarding the Veteran's increased headaches claim, the Board notes that the Veteran was afforded VA examinations in 2008 and 2009. In 2008, the Veteran reported a history of approximately three headaches per week, "now more often." His headaches lasted approximately 20 minutes and are usually three or four times usually on both sides of the frontal area with rhinorrhea present during attacks. He reported flashes of light before the headaches and that they last three to four hours and sometimes they may last as long as two to three days, which happens twice a month. Pain level is 10/10 the majority of the time and zolmitriptan helps reduce the duration of pain. The examiner did not address whether the headaches were characteristic prostrating attacks, and did not address why there were two descriptions of headaches-one headache that occurred three to four times per week and lasted 20 minutes, and one headache that lasted anywhere from three hours to two days, and it was not clear how frequently these headaches occurred per month. During a May 2009 VA examination, the Veteran reported his headaches occurred two to three times per week. They were described as debilitating and he had to take his Zomig and rest to get relief. Sometimes the headaches lasted more than one day and constant bedrest was required. Headaches are preceded by a jagged light prodrome and if he takes his medicine quickly he can sometimes limit the headache to a few hours. He reported weekly headaches in the past year, and that most attacks are prostrating for hours. The examination did not address whether the headaches were characteristically prostrating, whether they were productive of severe economic inadaptability, and again noted two headache types, one that occurred two to three times per week, and one that occurred weekly. On remand, the Veteran should be afforded another VA headache examination to address the current severity of his headaches. The Veteran contends that his pseudofolliculitis barbae (PFB) warrants a rating in excess of 10 percent. He was afforded a VA examination in January 2003 which noted that the Veteran had PFB on the face, and back of the neck. He did not take any medications, and he had no systemic symptoms such as weight loss or fever. In December 2003, the Veteran was given desonide lotion .05 percent, but it caused itching, burning and stinging on his face, and he discontinued use of the lotion. During a January 2007 examination, the Veteran was noted to have skin eruptions of papules and pustules about the beard area which were painful and tender. He was not using corticosteroids or other immunosuppressive drugs. He was noted to have PFB covering 40 percent of the face and neck. A July 2009 general medical examination noted hyperpigmentation with minute, raised rash on his anterior cervical area to his mid-cheek bilateral and was consistent with PFB. He was noted to have no excessive scarring, and that the area encompassed less than 3 percent of his entire body surface and approximately 10 percent of his facial area. PFB may be rated as dermatitis/eczema which requires information on the percentage of the entire body covered and percentage of exposed areas affected, or based on scars and the disfigurement of the head face or neck. The Veteran's claim for an increased rating for PFB must be remanded for an updated VA examination because the prior examinations are not sufficient to rate his disability. Lumbar, Hips and Loss of feeling in the hands and feet The Board reopened the Veteran's claim of entitlement to service connection for a lumbar spine disability above, and is remanding the claim for development via a VA nexus examination. Similarly, the Veteran was afforded a VA general medical examination in July 2009. He was diagnosed with bilateral hip strain, lumbar spine spondylosis and numbness and tingling of the extremities of an unknown origin. No medical nexus opinions were provided. The Veteran has contended that his lumbar spine, bilateral hip and extremity numbness are a result of his in-service motor vehicle accident. On remand, the Veteran should be afforded appropriate examinations and nexus opinions must be sought. SMC In Bradley v. Peake, 22 Vet. App. 280 (2008), the Court held that, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of TDIU predicated on a single disability may form the basis for an award of special monthly compensation. See Bradley v. Peake, 22 Vet. App. 280 (2008) (holding that there could be a situation where a veteran has a schedular total rating for a particular service-connected disability, and could establish a TDIU rating for another service-connected disability in order to qualify for special monthly compensation (SMC) under 38 U.S.C. § 1114(s) by having an "additional" disability of 60 percent or more ("housebound" rate)); see 38 U.S.C.A. § 1114(s). Thus, it is possible for a veteran first to be awarded TDIU based on a single disability and subsequently receive schedular disability ratings for other conditions that would not duplicate in the count of disabilities for special monthly compensation purposes (that is, separate disabilities that could combine for a 60 percent disability rating. The Veteran's claim for SMC is inextricably intertwined with the Veteran's claims for increased ratings. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Accordingly, the case is REMANDED for the following action: 1. Ongoing VA treatment records from 2009 to the present should be added to the virtual record. 2. Schedule the Veteran for a VA spine examination. After a review of the claims file, and examination and interview of the Veteran, the examiner should opine whether it is at least as likely as not (50/50 probability or greater) that the Veteran has a lumbar spine disability as a result of his military service. The examiner should specifically address whether the Veteran has a lumbar spine disability as a result of his 1973 motor vehicle accident. All opinions must be supported with a rationale/explanation. 3. Schedule the Veteran for a VA joint examination. After a review of the claims file, and examination and interview of the Veteran, the examiner should opine whether it is at least as likely as not (50/50 probability or greater) that the Veteran has a bilateral hip disability as a result of his military service. The examiner should specifically address whether the Veteran has a bilateral hip disability as a result of his 1973 motor vehicle accident. All opinions must be supported with a rationale/explanation. 4. Schedule the Veteran for a VA neurological or other appropriate examination regarding his claim for loss of feeling in the arms and legs. After a review of the claims file, and examination and interview of the Veteran, the examiner should opine whether it is at least as likely as not (50/50 probability or greater) that the Veteran has a disability which manifests in loss of feeling in the arms and legs as a result of his military service. The examiner should specifically address whether the Veteran a disability that manifests in loss of feeling in the arms and legs as a result of his 1973 motor vehicle accident. All opinions must be supported with a rationale/explanation. 5. Schedule the Veteran for a VA eye examination. After a review of the claims file, and examination and interview of the Veteran, the examiner should provide a list of the Veteran's eye diagnoses. Notably, refractive error is not on appeal. The examiner should provide an opinion as to whether it is at least as likely as not (50/50 probability or greater) that each of the diagnosed eye disabilities is a result of the Veteran's military service. The examiner should specifically address whether the Veteran has any eye disabilities as a result of his 1973 motor vehicle accident. All opinions must be supported with a rationale/explanation. 6. Schedule the Veteran for a VA joint examination to determine the current severity of the Veteran's right ankle disability. 7. Schedule the Veteran for a VA headache examination to determine the current severity of the Veteran's post-concussion migraines. The examiner should address the severity and frequency of the Veteran's headaches, to include if they are prostrating, and the examiner should address their functional/economic impact. 8. Schedule the Veteran for a VA skin examination to determine the current severity of his PFB. The examiner should address the skin disorder in regards to the percentage of body affected/percentage of exposed areas affected and regarding the signs of disfigurement under DC 7800. 9. After completion of the above, and any other development deemed warranted by the record, the AMC/RO should readjudicate the claims on appeal, in light of all pertinent evidence and legal authority. The AMC/RO should address the SMC claim in light of any changes made to the Veteran's disability ratings. If any benefit sought on appeal remains denied, the AMC should furnish an appropriate supplemental statement of the case (SSOC), and afford the Veteran and his representative the opportunity to provide additional argument in response thereto before the claims file is returned to the Board for further appellate consideration. 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 2014). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs