Citation Nr: 1601385 Decision Date: 01/13/16 Archive Date: 01/21/16 DOCKET NO. 13-12 841 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for a back disability, including as due to a service-connected bilateral knee disability. 2. Whether new and material evidence has been received to reopen a claim of service connection for a bilateral hip disability, including as due to a service-connected bilateral knee disability. 3. Whether new and material evidence has been received to reopen a claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia). 4. Entitlement to service connection for a back disability, including as due to a service-connected bilateral knee disability. 5. Entitlement to service connection for a bilateral hip disability, including as due to a service-connected bilateral knee disability. 6. Entitlement to service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia). 7. Entitlement to a compensable disability rating for residuals of a fracture of the fourth metatarsal of the left foot. 8. Entitlement to a disability rating greater than 10 percent for degenerative changes of the left knee. 9. Entitlement to a total disability rating based on individual unemployability (TDIU) due exclusively to service-connected bipolar disorder, a bilateral knee disability, and residuals of a fracture of the fourth metatarsal of the left foot. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from October 1971 to November 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, which determined that new and material evidence had not been received sufficient to reopen the Veteran's previously denied claims of service connection for a back disability and for a bilateral hip disability, each including as due to a service-connected bilateral knee disability. The RO also essentially reopened a previously denied claim of service connection for tachycardia (which it characterized as heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia) and denied this claim on the merits. The RO further denied the Veteran's claims for a compensable disability for residuals of a fracture of the fourth metatarsal of the left foot and for a 10 percent rating for degenerative changes of the left knee. The RO finally denied a claim of entitlement to a TDIU due exclusively to service-connected bipolar disorder, a bilateral knee disability, and residuals of a fracture of the fourth metatarsal of the left foot. The Veteran disagreed with this decision in August 2012 with respect to all of the claims adjudicated in June 2012 except for the denial of a TDIU. He perfected a timely appeal in April 2013 with respect to all of the claims adjudicated in June 2012 except for the denial of a TDIU. He disagreed with the denial of a TDIU in April 2013. He perfected a timely appeal with respect to the denial of a TDIU in June 2013. A Travel Board hearing was held at the RO in October 2015 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record. Having reviewed the record evidence, the Board finds that the issues on appeal should be recharacterized as stated on the title page of this decision. The Board observes that a change in diagnosis or the specificity of the claim must be considered carefully in determining whether the claim is based on a distinct factual basis. Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008). In Boggs, the United States Court of Appeals for the Federal Circuit found that a claim for one diagnosed disease or injury cannot be prejudiced by a prior claim for a different diagnosed disease or injury when it is an independent claim based on distinct factual bases. The Board also recognizes the holding in Velez v. Shinseki, 23 Vet. App. 199 (2009), that the focus of the analysis must be whether the evidence truly amounted to a new claim based upon a different diagnosed disease or whether the evidence substantiates an element of a previously adjudicated matter. In this case, the Board notes that the Veteran has been diagnosed as having heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia. As opposed to facts in Velez, however, the Veteran consistently has pursued a claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia. In that regard, the present request to reopen turns upon diagnoses and factual bases that were considered in prior decisions. Therefore, the threshold question of whether new and material evidence has been submitted must be addressed. The Board next observes that, in a December 2008 rating decision, the RO denied the Veteran's claims of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (which was characterized as tachycardia), a back disability, and for a bilateral hip disability. The Veteran did not appeal this decision, and it became final. See 38 U.S.C.A. § 7104 (West 2014). The Veteran also did not submit any statements relevant to these claims within 1 year of the December 2008 rating decision which would render this decision non-final for VA purposes under 38 C.F.R. § 3.156(b). See Buie v Shinseki, 24 Vet. App. 242, 251-52 (2011) (explaining that, when statements are received within one year of a rating decision, the Board's inquiry is not limited to whether those statements constitute notices of disagreement but whether those statements include the submission of new and material evidence under 38 C.F.R. § 3.156(b)). The Board does not have jurisdiction to consider a claim that has been adjudicated previously unless new and material evidence is presented. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Therefore, the issues of whether new and material evidence has been received to reopen claims of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), a back disability, and for a bilateral hip disability, are as stated on the title page. Regardless of the RO's actions, the Board must make its own determination as to whether new and material evidence has been received to reopen these claims. That is, the Board has a jurisdictional responsibility to consider whether a claim should be reopened. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). This appeal was processed using the Virtual VA (VVA) and Virtual Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into consideration the existence of these electronic records. The issue of entitlement to additional compensation based on the dependency of the Veteran's parent (his mother) has been raised by the record in a September 2015 statement but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over this claim and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). As is explained below in greater detail, new and material evidence has been received sufficient to reopen the previously denied claims of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), a back disability, and for a bilateral hip disability. The issues of entitlement to service connection for a back disability, entitlement to service connection for a bilateral hip disability, entitlement to a compensable disability rating for residuals of a fracture of the fourth metatarsal of the left foot, entitlement to a disability rating greater than 10 percent for degenerative changes of the left knee, and entitlement to a TDIU due exclusively to service-connected bipolar disorder, a bilateral knee disability, and residuals of a fracture of the fourth metatarsal of the left foot are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. In a rating decision dated on December 23, 2008, the RO denied the Veteran's claims of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia) (which was characterized as tachycardia), a back disability, and a bilateral hip disability; this decision was not appealed and became final. 2. The evidence received since the December 2008 rating decision relates to unestablished facts necessary to substantiate the claims of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), a back disability, and a bilateral hip disability because it shows that he experiences current heart disease, back disability, and bilateral hip disability which may be attributable to active service. 3. The record evidence shows that the Veteran's current heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), is not related to active service. CONCLUSIONS OF LAW 1. The December 2008 rating decision, which denied the Veteran's claims of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), a back disability, and for a bilateral hip disability, is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.302 (2015). 2. Evidence received since the December 2008 RO decision in support of the claims of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), a back disability, and for a bilateral hip disability is new and material; thus, these claims are reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2015). 3. Heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), was not incurred in or aggravated by active service nor may it be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. Given the favorable disposition of the Veteran's request to reopen the claim of service connection for a back disability and for a bilateral hip disability, which is not prejudicial to him, the Board finds that all notification and development actions needed to fairly adjudicate this aspect of the appeal have been accomplished. With respect to the Veteran's request to reopen the claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), the Board notes that, in letters issued in December 2010, January 2011, and in January 2012, VA notified the Veteran of the information and evidence needed to substantiate and complete this claim, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters informed the Veteran to submit medical evidence relating the claimed disability to active service and noted other types of evidence the Veteran could submit in support of this claim. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of these letters, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of this claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The December 2010 letter defined new and material evidence, advised the Veteran of the reasons for the prior denial of the claim of service connection, and noted the evidence needed to substantiate the underlying claim. That correspondence satisfied the notice requirements as defined in Kent v. Nicholson, 20 Vet. App. 1 (2006). Additional notice of the five elements of a service-connection claim was provided in all of the VCAA notice issued during the pendency of this appeal, as is required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided with complete notice of VA's duties to notify and assist him with respect to a service connection claim in December 2010, January 2011, and in January 2012. He also has submitted argument and evidence in support of the underlying service connection claim for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), on the merits. Because the Veteran has received a full and fair opportunity to participate in the adjudication of his claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), the Board finds that it may adjudicate the merits of the underlying service connection claim without prejudice to the Veteran. See Bernard, 4 Vet. App. at 393. As will be explained below in greater detail, although the evidence supports reopening the Veteran's claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), it does not support granting this claim on the merits. Because the Veteran was fully informed of the evidence needed to substantiate this claim, any failure of the AOJ to notify the Veteran under the VCAA cannot be considered prejudicial. Id. The Veteran also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With respect to the timing of the notice, the Board points out that the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini, 18 Vet. App. at 112. Here, all relevant notice was issued prior to the currently appealed rating decisions; thus, this notice was timely. There has been no prejudice to the Veteran and any defect in the timing or content of the notices has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the AOJ and the Board. It appears that all known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file. The Veteran's electronic paperless claims files in Virtual VA and in Veterans Benefits Management System (VBMS) have been reviewed. The Veteran's complete Social Security Administration (SSA) records also have been obtained and associated with the claims file. The Veteran contends that he was hospitalized at the Altus Air Force Base, Oklahoma, during active service for treatment of tachycardia. His service representative asserted at the October 2015 Board hearing that the Veteran's inpatient hospitalization records from this in-service hospitalization had not yet been obtained by the AOJ. As is explained below in greater detail, the record evidence demonstrates that, although he was treated as an outpatient, the Veteran was not hospitalized for treatment of tachycardia at any time during active service. As such, a remand to attempt to obtain the alleged in-patient records is not required. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the basis of the prior determination and noted the element of the claim that was lacking to substantiate the claim for benefits. The VLJ specifically noted the issues as including the issues listed on the title page of this decision. The Veteran was assisted at the hearing by an accredited representative from Disabled American Veterans. The representative and the VLJ then asked questions to ascertain whether the Veteran had submitted evidence in support of this claim. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims file that might have been overlooked or was outstanding that might substantiate the claim. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) nor identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the element necessary to substantiate the claim and the Veteran, through his testimony, demonstrated that he had actual knowledge of the element necessary to substantiate his claim for benefits. The Veteran's representative and the VLJ asked questions to draw out the evidence which supported the Veteran's claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that any error in notice provided during the Veteran's hearing constitutes harmless error. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. An examination or opinion shall be treated as being necessary to make a decision on the claim if the evidence of record, taking into consideration all information and lay or medical evidence (including statements of the claimant) contains competent evidence that the claimant has a current disability, or persistent or recurring symptoms of disability; and indicates that the disability or symptoms may be associated with the claimant's active service; but does not contain sufficient medical evidence for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). VA need not conduct an examination or obtain a medical opinion with respect to the issue of whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection because the duty under 38 C.F.R. § 3.159(c)(4) applies to a claim to reopen only if new and material evidence is presented or secured. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran has been provided with VA examinations which address the contended causal relationship between heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), and active service. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 79. Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claim adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. New and Material Evidence Claims The Veteran contends that new and material evidence has been received sufficient to reopen the previously denied claims of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), a back disability, and a bilateral hip disability. He essentially contends that the newly received evidence shows that he experiences current heart disease, back disability, and bilateral hip disability that is attributable to active service. He also contends that a service-connected bilateral knee disability caused or contributed to his current back and bilateral hip disabilities. Laws and Regulations In December 2008, the AOJ denied, in pertinent part, the Veteran's claims of service connection for a back disability, a bilateral hip disability, and for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (which was characterized as tachycardia). A finally adjudicated claim is an action 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. §§ 7104, 7105 (West 2014); 38 C.F.R. §§ 3.160(d), 20.302, 20.1103 (2015). The Veteran did not initiate an appeal of the December 2008 rating decision and it became final. The Veteran also did not submit any statements relevant to this claim within 1 year of the December 2008 rating decision which would render this decision non-final for VA purposes under 38 C.F.R. § 3.156(b). See Buie, 24 Vet. App. at 251-52. The claims of service connection for a back disability, a bilateral hip disability, and for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), may be reopened if new and material evidence is received. Manio v. Derwinski, 1 Vet. App. 140 (1991). The Veteran filed an application to reopen his previously denied service connection claims for a back disability, a bilateral hip disability, and for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (which he characterized as tachycardia), on a VA Form 21-526b which was date stamped as received by the AOJ on November 18, 2010. New and material evidence is defined by regulation. See 38 C.F.R. § 3.156(a) (2015). As relevant to this appeal, 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. Id. In determining whether evidence is new and material, the credibility of the new evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). With respect to the Veteran's application to reopen a claim of service connection for a back disability, including as due to a bilateral knee disability, the evidence before VA at the time of the prior final AOJ decision in December 2008 consisted of the Veteran's service treatment records and post-service VA and private treatment records, his SSA records, and his lay statements. The AOJ stated that the Veteran had a work-related back injury in 2007 and also had been treated for other back disabilities beginning in approximately 2007. The AOJ also stated that the evidence did not indicate that the Veteran's back disability was related to active service, including as due to a bilateral knee disability. Thus, the claim was denied. The newly received evidence includes additional VA treatment records and examination reports and the Veteran's lay statements, his July 2012 RO hearing testimony, and his October 2015 Board hearing testimony. All of this newly received evidence is to the effect that the Veteran currently experiences a back disability that is related to active service. For example, Dr. B. stated in an August 2012 Independent Medical Evaluation that the Veteran's back complaints were related to "cumulative trauma secondary to football as well as serving as Supply Officer in the 443rd Supply Squadron" during active service. The Board notes that the evidence which was of record at the time of the prior final RO decision in December 2008 did not indicate that the Veteran's back disability was attributable to active service. The newly received evidence suggests that this disability may be related to active service. The Board observes in this regard that, in Shade, 24 Vet. App. at 110, the Court held that the phrase "raises a reasonable possibility of substantiating the claim" found in the post-VCAA version of 38 C.F.R. § 3.156(a) must be viewed as "enabling" reopening of a previously denied claim rather than "precluding" it. All of the newly received evidence is presumed credible for the limited purpose of reopening the previously denied claim. See also Justus, 3 Vet. App. at 513. Thus, the Board finds that the evidence submitted since December 2008 is new, in that it has not been submitted previously to agency adjudicators, and is material, in that it relates to an unestablished fact necessary to substantiate the claim of service connection for a back disability, including as due to a service-connected bilateral knee disability, and raises a reasonable possibility of substantiating this claim. Because new and material evidence has been received, the Board finds that the previously denied claim of service connection for a back disability, including as due to a service-connected bilateral knee disability, is reopened. With respect to the Veteran's application to reopen a claim of service connection for a bilateral hip disability, including as due to a bilateral knee disability, the evidence before VA at the time of the prior final AOJ decision in December 2008 consisted of the Veteran's service treatment records and post-service VA and private treatment records, his SSA records, and his lay statements. The AOJ stated that the Veteran's post-service private treatment records showed diagnoses of a bilateral hip disability (which was characterized as right hip strain and sciatica). The AOJ also stated that there was no evidence relating the Veteran's current bilateral hip disability to a service-connected bilateral knee disability. Thus, the claim was denied. The newly received evidence includes additional VA treatment records and examination reports and the Veteran's lay statements, his July 2012 RO hearing testimony, and his October 2015 Board hearing testimony. All of this newly received evidence is to the effect that the Veteran currently experiences a bilateral hip disability (diagnosed as chronic bilateral hip strain following VA hip and thigh conditions Disability Benefits Questionnaire (DBQ) in March 2013) that is related to active service, including as due to a service-connected bilateral knee disability. The Board notes that the evidence which was of record at the time of the prior final RO decision in December 2008 did not indicate that the Veteran's bilateral hip disability was attributable to active service. The newly received evidence suggests that, in fact, this disability may be related to active service. The Board observes in this regard that, in Shade, 24 Vet. App. at 110, the Court held that the phrase "raises a reasonable possibility of substantiating the claim" found in the post-VCAA version of 38 C.F.R. § 3.156(a) must be viewed as "enabling" reopening of a previously denied claim rather than "precluding" it. All of the newly received evidence is presumed credible for the limited purpose of reopening the previously denied claim. See also Justus, 3 Vet. App. at 513. Thus, the Board finds that the evidence submitted since December 2008 is new, in that it has not been submitted previously to agency adjudicators, and is material, in that it relates to an unestablished fact necessary to substantiate the claim of service connection for a bilateral hip disability, including as due to a service-connected bilateral knee disability, and raises a reasonable possibility of substantiating this claim. Because new and material evidence has been received, the Board finds that the previously denied claim of service connection for a bilateral hip disability, including as due to a service-connected bilateral knee disability, is reopened. With respect to the Veteran's application to reopen a claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), the evidence before VA at the time of the prior final AOJ decision in December 2008 consisted of the Veteran's service treatment records, his SSA records, and his lay statements. The AOJ stated that the Veteran's SSA records showed that he had multiple cardiovascular diagnoses (including coronary artery disease, angina, and hypertension). The AOJ also stated that there was no evidence showing a medical nexus between the Veteran's current heart disease and active service. Thus, the claim was denied. The newly received evidence includes additional VA treatment records and examination reports and the Veteran's lay statements, his July 2012 RO hearing testimony, and his October 2015 Board hearing testimony. All of this newly received evidence is to the effect that the Veteran currently experiences heart disease (diagnosed as atherosclerotic cardiovascular disease following VA heart conditions Disability Benefits Questionnaire (DBQ) in March 2012) which is attributable to active service. The Board notes that the evidence which was of record at the time of the prior final RO decision in December 2008 did not indicate that the Veteran's heart disease was attributable to active service. The newly received evidence suggests that this disability may be related to active service. The Board observes in this regard that, in Shade, 24 Vet. App. at 110, the Court held that the phrase "raises a reasonable possibility of substantiating the claim" found in the post-VCAA version of 38 C.F.R. § 3.156(a) must be viewed as "enabling" reopening of a previously denied claim rather than "precluding" it. All of the newly received evidence is presumed credible for the limited purpose of reopening the previously denied claim. See also Justus, 3 Vet. App. at 513. Thus, the Board finds that the evidence submitted since December 2008 is new, in that it has not been submitted previously to agency adjudicators, and is material, in that it relates to an unestablished fact necessary to substantiate the claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), and raises a reasonable possibility of substantiating this claim. Because new and material evidence has been received, the Board finds that the previously denied claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), is reopened. Having reopened the Veteran's previously denied claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), the Board will proceed to adjudicate this claim on the merits. Service Connection Claim for Heart Disease The Veteran contends that he incurred heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (which he characterized as tachycardia), during active service. He specifically contends that he initially experienced tachycardia while hospitalized at Altus Air Force Base, Oklahoma, during service and has experienced continuous disability due to tachycardia since service. Laws and Regulations Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. 1110, 1131 (West 2014); 38 C.F.R. 3.303(a) (2015). Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection also may be granted for any disease 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). Certain chronic diseases, including cardiovascular-renal disease, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires (1) medical evidence of a presently existing disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. In Walker, the Federal Circuit overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also Fountain v. McDonald, 27 Vet. App. 258 (2015) (adding tinnitus as an "organic disease of the nervous system" to the list of disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a)). Because cardiovascular-renal disease is considered a "chronic" disability under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology remains valid in adjudicating the Veteran's claim. It is VA policy to administer the laws and regulations governing disability claims under a broad interpretation and consistent with the facts shown in every case. When a reasonable doubt arises regarding service origin, the degree of disability, or any other point, after careful consideration of all procurable and assembled data, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not prove or disprove the claim satisfactorily. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Factual Background and Analysis The Board finds that the preponderance of the evidence is against granting the Veteran's claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia). The Veteran contends that he incurred heart disease during active service or, alternatively, his current heart disease initially was diagnosed following an in-service hospitalization for tachycardia and has continued since his service separation. The record evidence does not support his assertions regarding an etiological link between his current heart disease (diagnosed as atherosclerotic cardiovascular disease) and active service. With respect to the assertions advanced by the Veteran's service representative at the October 2015 hearing that the Veteran was hospitalized at Altus Air Force Base, Oklahoma, for treatment of tachycardia during service, the Board notes initially that a review of the Veteran's service treatment records does not suggest that he was hospitalized at any time during active service for tachycardia. These records show instead that, on outpatient treatment at Altus Air Force Base, Oklahoma, on December 21, 1972, he complained of "chest pain, tachycardia, etc," and headaches and dizziness. The in-service clinician stated, "I massaged [right] carotid and pulse immediately converted to 100-105." Physical examination showed a regular heart rate and rhythm. The Veteran's pulse was 210 and his blood pressure was 128/76. An echocardiogram (EKG) was within normal limits. The impression was paroxysmal atrial tachycardia. The in-service clinician stated that the Veteran would be observed. At 2pm on December 21, 1972, this clinician stated that the Veteran was "[d]oing well. Will let go." He recommended that the Veteran make an internal medicine appointment for follow-up. Having reviewed the Veteran's service treatment records, the Board concludes that, at best, they show that the Veteran was observed in an outpatient clinic on December 21, 1972. The Board acknowledges that these records are handwritten and do not indicate how long the Veteran was observed on this date. Nevertheless, these records do not indicate that the Veteran was admitted to the hospital on December 21, 1972, and there is no other indication in his service treatment records that he was hospitalized at any other time during active service for tachycardia. The Board notes in this regard that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). The post-service evidence also does not support granting the Veteran's claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia). It shows instead that, although the Veteran was diagnosed as having atherosclerotic cardiovascular disease following VA heart conditions DBQ in March 2012, this disability is not related to active service. For example, on private outpatient treatment in January 2003, the Veteran complained of chest pain and shortness of breath. He had not been seen for 3-4 years. His chest pains were sharp and last up to 1 hour. He drank 2 cups of caffeine per day, did not exercise regularly, and worked up to 60 hours a week where he was under a lot of stress. Physical examination showed blood pressure of 138/98, clear lungs, and a regular heart rate and rhythm. An EKG showed a normal sinus rhythm. The impression was chest pain/palpation. In October 2004, the Veteran complained of dyspnea on exertion, chest discomfort with exertion, and increasing fatigue. A history of past chest palpitations with no diagnosis and a racing heartbeat was noted. He quit smoking 9 years earlier with a 20-30 pack per year smoking history beforehand. Physical examination showed an obese male with blood pressure of 114/68 and 116/62, non-labored breathing, and normal cardiac rhythm. An EKG showed normal sinus rhythm. The impressions included angina pectoris and palpitations consistent with supraventricular tachycardia. The Veteran was hospitalized at a private facility for 2 days in June 2007 following complaints of chest pain. A private EKG showed mild mitral regurgitation. A private cardiac catheterization showed moderate 2-vessel coronary artery disease. The discharge diagnoses included new-onset exertional angina without evidence of myocardial infarction with strong familial history of coronary artery disease and a history of supraventricular tachycardia. On private outpatient treatment in July 2007, it was noted that the Veteran had been "found to have exertional angina and had cardiac catheterization showing mild to moderate stenosis in several vessels." Physical examination showed blood pressure of 120/70, heart sounds "very distant, almost inaudible, but regular rate, and clear lungs. A computerized tomography (CT) scan was negative. The impressions included exertional angina "with known cardiac catheterization evidenced coronary artery disease." In December 2007, the Veteran's complaints included "rushes and tingling...He states it begins in the chest and begins to rush in the chest up through the neck into the mouth with tingling and then rushes into the hands, down the arms, and to the hands where he gets [a] pricking type sensation. He states this will continue and and then dissipate and continue and then dissipate." A history of known coronary artery disease was noted. A cardiac catheterization showed mild to moderate blockage in several arteries. Physical examination showed blood pressure of 120/70, clear lungs, and a regular heart rate and rhythm. The impressions included coronary artery disease. On SSA medical evaluation in August 2008, the Veteran's complaints included chest pain "over the pericardial area with a tight, squeezing pain which is associated with radiation into the jaw and left arm. He states it is a 10/10." His chest pain lasted between 1-10 minutes and was "associated with shortness of breath and sweatiness." A positive history of heart disease was noted. He smoked 3 packs per day for 27 years but quit smoking in 1995. Physical examination showed blood pressure of 138/95, clear lungs, and a regular heart rate and rhythm. The assessment included a history of coronary artery disease and angina. On VA heart conditions Disability Benefits Questionnaire (DBQ) in March 2012, the Veteran complained of "chest pains on and off" since being diagnosed as having coronary artery disease. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran had experienced 1-3 episodes of intermittent (paroxysmal) cardiac arrhythmia (or tachycardia) which was being monitored. He also had angioplasty in February 2011. Physical examination showed a regular heart rate and rhythm with the point of maximal impact at the fourth intercostal space, normal heart sounds, and clear lungs to auscultation. An EKG taken in September 2012 was normal. A chest x-ray showed no acute pulmonary process and evidence of prior granulomatous disease. Myocardial perfusion testing showed no "convincing" myocardial ischemia. An exercise stress test was normal. The VA examiner opined that it was less likely than not that the Veteran's heart condition (which he diagnosed as paroxysmal tachycardia arrhythmia) was related to active service. The rationale for this opinion was that the reported in-service tachycardia was not a diagnosis and the Veteran was found qualified for worldwide duty with no heart disease concerns. The rationale also was that coronary artery disease "is an established cause of paroxysmal arrhythmias." The diagnosis was atherosclerotic cardiovascular disease. The Veteran testified at his October 2015 Board hearing that he had been hospitalized during active service for treatment of tachycardia. See Board hearing transcript dated October 8, 2015, at pp. 5. He also testified that he been treated on multiple occasions following service for heart problems. Id., at pp. 5-7. The Board acknowledges that the Veteran currently experiences heart disease which he attributes to active service. The Board also acknowledges again that the newly received evidence is presumed credible only for the limited purpose of reopening the previously denied claim. The record evidence does not support granting the Veteran's reopened claim on the merits, however, because it does not show an etiological link between his current heart disease (diagnosed as atherosclerotic cardiovascular disease) and active service. For example, the March 2012 VA examiner specifically found that there was no etiological link between this disability and active service. This opinion was fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Veteran also has not identified or submitted any evidence, to include a medical nexus, which demonstrates his entitlement to service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia). Thus, the claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia) is denied. The Board next notes that the Veteran is not entitled to service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia) on a presumptive basis as a chronic disease. See 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Despite the Veteran's assertion to the contrary, the evidence does not indicate that he experienced heart disease during active service or within the first post-service year (i.e., by November 1975) such that service connection is warranted for this disability on a presumptive basis. Id. The Board again acknowledges that the Veteran was diagnosed as having tachycardia while on active service in December 1972. The March 2012 VA examiner concluded that this was not a valid diagnosis, however. The Veteran's service treatment records also do not demonstrate that the Veteran experienced chronic cardiovascular-renal disease at any time during service. Thus, service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia) on a presumptive basis as a chronic disease is not warranted. Id. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown,6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A Veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr, 21 Vet. App. at 309. The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan, 451 F.3d at 1337; Barr, 21 Vet. App. at 303. In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). As part of the current VA disability compensation claim, in recent statements and sworn testimony, the Veteran has asserted that his symptoms of heart disease have been continuous since service. He asserts that he continued to experience symptoms relating to heart disease (tachycardia) after he was discharged from service. In this case, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of heart disease after service separation. Further, the Board concludes that his assertion of continued symptomatology since active service, while competent, is not credible. The Board finds that the Veteran's more recently-reported history of continued symptoms of heart disease since active service is inconsistent with the other lay and medical evidence of record. Indeed, while he now asserts that his disorder began in service, in the more contemporaneous medical history he gave at the service separation examination, he denied any relevant history or complaints of symptoms. Specifically, the service separation examination report reflects that the Veteran was examined and his heart was found to be normal clinically. His in-service history of symptoms at the time of service separation is more contemporaneous to service so it is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later). The post-service medical evidence does not reflect complaints or treatment related to heart disease for several decades following active service. The Board emphasizes the multi-year gap between discharge from active service (1974) and initial reported symptoms related to heart disease (which were diagnosed as chest pain/palpitation) in 2003 (a 29-year gap). See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (finding lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where Veteran failed to account for lengthy time period between service and initial symptoms of disability). The Board notes that the Veteran sought treatment for a myriad of medical complaints since discharge from service, including residuals of a fracture of the fourth metatarsal of the left foot, bipolar disorder, and degenerative changes of the left knee. Significantly, during that treatment, when he specifically complained of other problems, he never reported complaints related to heart disease. Rucker, 10 Vet. App. at 67 (holding that lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). When the Veteran sought to establish medical care for heart disease with a private clinician after service in January 2003, he did not report the onset of heart disease symptomatology during or soon after service or even indicate that the symptoms were of longstanding duration. Instead, it was noted that the Veteran had not been seen for several years prior to being seen for a complaint of chest pain/palpation. Such histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes. Id. The Veteran filed VA disability compensation claims for service connection for a bilateral knee disability in 1976, shortly after service, but did not claim service connection for heart disease or make any mention of any relevant symptomatology. He did not claim that symptoms of his disorder began in (or soon after) service until he filed his current VA disability compensation claim in November 2010. Such statements made for VA disability compensation purposes are of lesser probative value than his previous more contemporaneous in-service histories and his previous statements made for treatment purposes. See Pond v. West, 12 Vet. App. 341 (1999) (finding that, although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service. See Madden, 125 F.3d at 1481 (finding Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the absence of complaints or treatment for years after service, his previous statements made for treatment purposes, and the record evidence showing no etiological link between his current heart disease and active service. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service separation. ORDER As new and material evidence has been received, the previously denied claim of service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), is reopened; to this extent only, the appeal is granted. Entitlement to service connection for heart disease, to include arteriosclerotic cardiovascular disease with paroxysmal tachycardia arrthymia (previously characterized as tachycardia), is denied. As new and material evidence has been received, the previously denied claim of service connection for a back disability, including as due to a service-connected bilateral knee disability, is reopened; to this extent only, the appeal is granted. As new and material evidence has been received, the previously denied claim of service connection for a bilateral hip disability, including as due to a service-connected bilateral knee disability, is reopened; to this extent only, the appeal is granted. REMAND The Veteran contends that he incurred a back disability and a bilateral hip disability during active service; as noted above, the Board has reopened both of these previously denied service connection claims. He alternatively contends that a service-connected bilateral knee disability caused or aggravated (permanently worsened) his back and bilateral hip disabilities. The Veteran also contends that both his service-connected residuals of a fracture of the fourth metatarsal of the left foot and his service-connected degenerative changes of the left knee are more disabling than currently evaluated. He specifically contends that he experiences constant daily left foot pain as a residual of his fracture of the fourth metatarsal of the left foot and has difficulty standing and walking due to his left knee disability. He further contends that he is precluded from securing or maintaining substantially gainful employment solely as a result of his service-connected bipolar disorder, residuals of a fracture of the fourth metatarsal of the left foot, and bilateral knee disability, entitling him to a TDIU. Having reviewed the record evidence, the Board finds that additional development is required before the underlying claims can be adjudicated on the merits. With respect to the Veteran's reopened service connection claim for a back disability, including as due to a service-connected bilateral knee disability, the Board notes that, although the opinion from Dr. B. provided in August 2012 was sufficient to reopen the previously denied claim because it was presumed credible for the limited purpose of reopening this claim, it is insufficient to adjudicate the reopened claim on the merits. A detailed review of this opinion purporting to relate the Veteran's back disability to active service indicates that it is based on what the Veteran reported to this clinician. It also does not address the Veteran's 2007 on-the-job back injury which resulted in surgery and ended his prior employment. The Court has held that the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. Wilson v. Derwinski, 2 Vet. App. 614 (1992). A medical opinion based upon an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). A bare conclusion, even one reached by a medical professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A bare transcription of lay history, unenhanced by additional comment by the transcriber, does not become competent medical evidence merely because the transcriber is a medical professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). The Court also has held that the 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." Bloom v. West, 12 Vet. App. 185, 187 (1999). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Having reviewed Dr. B's August 2012 opinion, the Board finds that it is inadequate for VA adjudication purposes. The only other opinion of record addressing whether the Veteran's back disability is related to active service comes from the VA examiner in March 2013 and it also is insufficient to adjudicate the reopened claim. A detailed review of the March 2013 VA examiner's opinion shows that this examiner found the absence of treatment records for a back disability persuasive support for his negative nexus opinion concerning the contended causal relationship between the Veteran's back disability and active service. It is well-settled that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan, 451 F.3d at 1337; Barr, 21 Vet. App. at 303. There is no other opinion of record addressing the contended causal relationship between the Veteran's back disability and active service. The Board notes in this regard that VA's duty to assist includes providing an examination where necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Thus, the Board finds that, on remand, the Veteran should be scheduled for another VA examination to determine the nature and etiology of his back disability. With respect to the Veteran's reopened service connection claim for a bilateral hip disability, including as due to a service-connected bilateral knee disability, the Board again notes that, although the VA examiner's opinion in March 2013 is presumed credible for the limited purpose of reopening this claim, it is inadequate for adjudicating this claim on the merits. A detailed review of the March 2013 VA examiner's opinion indicates that he was not asked to provide, and he did not provide, an opinion concerning the contended causal relationship between a bilateral hip disability (which he diagnosed as bilateral hip strain) and active service on a direct service connection basis. See 38 C.F.R. §§ 3.303, 3.304. Instead, this examiner provided a negative nexus opinion concerning the contended causal relationship between the Veteran's service-connected bilateral knee disabilities and his bilateral hip disability. See also 38 C.F.R. § 3.310. There is no other opinion of record concerning the contended causal relationship between the Veteran's bilateral hip disability and active service. The Board again notes that VA's duty to assist includes providing an examination where necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Thus, the Board finds that, on remand, the Veteran should be scheduled for another VA examination to determine the nature and etiology of his bilateral hip disability. With respect to the Veteran's increased rating claims for residuals of a fracture of the fourth metatarsal of the left foot and degenerative changes of the left knee, the Board notes that the most recent VA examination for the left foot occurred in March 2012 and the most recent VA examination for the left knee occurred in July 2012. The Veteran testified extensively before the Board in October 2015 that both of these disabilities had worsened since his most recent VA examinations. See Board hearing transcript dated October 8, 2015, at pp. 8-16. As noted elsewhere, VA's duty to assist under the VCAA includes obtaining an examination or medical opinion when necessary. The Court has held that when a Veteran alleges that his service-connected disability has worsened since he was examined previously, a new examination may be required to evaluate the current degree of impairment. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Given the Veteran's contentions, and given the length of time which has elapsed since his most recent VA examinations for the left foot in March 2012 and for the left knee in July 2012, the Board finds that, on remand, he should be scheduled for updated VA examinations to determine the current nature and severity of his service-connected residuals of a fracture of the fourth metatarsal of the left foot and his service-connected degenerative changes of the left knee. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159. With respect to the Veteran's TDIU claim, the Board notes that, because adjudication of the increased rating claims for residuals of a fracture of the fourth metatarsal of the left foot and for degenerative changes of the left knee likely will impact adjudication of the TDIU claim, these claims are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that 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). Thus, adjudication of the Veteran's TDIU claim must be deferred. The AOJ also should attempt to obtain the Veteran's updated VA and private treatment records. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and/or his service representative and ask him to identify all VA and non-VA clinicians who have treated him for a back disability or for a bilateral hip disability since his service separation. Ask him to identify all VA and non-VA clinicians who have treated him for his service-connected residuals of a fracture of the fourth metatarsal of the left foot or his service-connected degenerative changes of the left knee in recent years. Obtain all VA treatment records which have not been obtained already. Once signed releases are received from the Veteran, obtain all private treatment records which have not been obtained already. A copy of any records obtained, to include a negative reply, should be included in the claims file. 2. Thereafter, schedule the Veteran for appropriate VA examination to determine the nature and etiology of his back disability. The claims file and a copy of this remand must be provided to the examiner for review. All appropriate testing should be conducted. The Veteran should be asked to provide a complete medical history, if possible. Based on a review of the claims file and the results of the Veteran's physical examination, and the Veteran's statements regarding the development and treatment of his claimed disorder, the examiner is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that a back disability, if diagnosed, is related to active service or any incident of service. The examiner also is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's service-connected bilateral knee disability caused or aggravated (permanently worsened) his back disability, if diagnosed. A complete rationale must be provided for any opinions expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the examiner must explain why this is so. 3. Thereafter, schedule the Veteran for appropriate VA examination to determine the nature and etiology of his bilateral hip disability. The claims file and a copy of this remand must be provided to the examiner for review. All appropriate testing should be conducted. The Veteran should be asked to provide a complete medical history, if possible. Based on a review of the claims file and the results of the Veteran's physical examination, and the Veteran's statements regarding the development and treatment of his claimed disorder, the examiner is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that a bilateral hip disability, if diagnosed, is related to active service or any incident of service. The examiner also is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's service-connected bilateral knee disability caused or aggravated (permanently worsened) his bilateral hip disability, if diagnosed. A complete rationale must be provided for any opinions expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the examiner must explain why this is so. 4. Thereafter, schedule the Veteran for appropriate examination to determine the current nature and severity of his service-connected residuals of a fracture of the fourth metatarsal of the left foot. The claims file and a copy of this remand must be provided to the examiner for review. All appropriate testing should be conducted. The Veteran should be asked to provide a complete medical history, if possible. Based on a review of the claims file and the results of the Veteran's physical examination, and the Veteran's statements regarding the development and treatment of his claimed disorder, the examiner is asked to state whether the Veteran's service-connected residuals of a fracture of the fourth metatarsal of the left foot are manifested by moderate foot injuries. The examiner next is asked to state whether the Veteran's service-connected residuals of a fracture of the fourth metatarsal of the left foot are manifested by moderately severe foot injuries. The examiner next is asked to state whether the Veteran's service-connected residuals of a fracture of the fourth metatarsal of the left foot are manifested by severe foot injuries. The examiner finally is asked to state whether the Veteran's service-connected residuals of a fracture of the fourth metatarsal of the left foot, alone or in combination with his other service-connected disabilities, preclude him from securing or following a substantially gainful occupation. A complete rationale must be provided for any opinions expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the examiner must explain why this is so. 5. Thereafter, schedule the Veteran for appropriate examination to determine the current nature and severity of his service-connected degenerative changes of the left knee. The claims file and a copy of this remand must be provided to the examiner for review. All appropriate testing should be conducted. The Veteran should be asked to provide a complete medical history, if possible. Based on a review of the claims file and the results of the Veteran's physical examination, and the Veteran's statements regarding the development and treatment of his claimed disorder, the examiner is asked to state whether the Veteran's service-connected degenerative changes of the left knee are manifested by flexion limited to 30 degrees. The examiner next is asked to state whether the Veteran's service-connected degenerative changes of the left knee are manifested by flexion limited to 15 degrees. The examiner finally is asked to state whether the Veteran's service-connected degenerative changes of the left knee, alone or in combination with his other service-connected disabilities, preclude him from securing or following a substantially gainful occupation. A complete rationale must be provided for any opinions expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the examiner must explain why this is so. 6. The Veteran should be given adequate notice of the requested examinations which includes advising him of the consequences of his failure to report to the examinations. If he fails to report to the examinations, then this fact should be noted in the claims file and a copy of the scheduling of examination notification or refusal to report notice, whichever is applicable, should be obtained by the RO and associated with the claims file. 7. Review all evidence received since the last prior adjudication and readjudicate the Veteran's claims. If the determination remains unfavorable to the Veteran, then the RO should issue a supplemental statement of the case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issues. An appropriate period of time should be allowed for response by the Veteran and his service representative. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. 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). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs