Citation Nr: 1617438
Decision Date: 05/02/16	Archive Date: 05/26/16

DOCKET NO. 14-23 995    DATE  MAY 05 2016


On appeal from theDepartment of Veterans Affairs Regional Office in Lincoln, Nebraska



THE ISSUES

1.  Entitlement to an effective date prior to November 4, 2011, for the grant of service connection for a scar on the left knee.

2. Entitlement to a rating in excess of 50 percent for an acquired psychiatric disorder.

3. Entitlement to an initial rating in excess of 10 percent for a right knee disability.

4. Entitlement to a rating in excess of 30 percent for a left knee disability, status­ post total knee replacement.

5. Entitlement to a compensable rating for scars on the knees

6. Entitlement to a rating in excess of 80 percent for vitiligo.

7. Entitlement to special monthly compensation based on loss of use under
38 U.S.C.A. § ll14(k).

8. Whether new and material evidence has been submitted in order to reopen a previously denied claim of entitlement to service connection for carpal tunnel syndrome, also claimed as numbness in the hands, a back disorder, a right shoulder disorder and obesity.

9. Entitlement to service connection for a respiratory disorder. 

10. Entitlement to service connection for a back disorder.

11. Entitlement to service connection for carpal tunnel syndrome, also claimed as numbness in the hands.

12. Entitlement to service connection for a gastrointestinal disorder, to include a secondary to vitiligo and an acquired psychiatric disorder.

13. Entitlement to service connection for hypertension.

14. Entitlement to service connection for a hernia.

15. Entitlement to service connection for an eye disorder, to include as secondary to vitiligo.

16. Entitlement to service connection for hypercholesterolemia.

17. Entitlement to service connection for irregular blood sugar levels, to include as secondary to vitiligo.

18. Entitlement to service connection for bilateral hearing loss, to include as secondary to medications taken for service-connected disabilities.

19. Entitlement to service connection for tinnitus, to include as secondary to medications taken for service-connected disabilities.

20. Entitlement to special monthly compensation (SMC) based on housebound status.

21. Entitlement to Dependents Educational Assistance benefits.

22. Entitlement to a total disability rating based on individual unemployability (TDIU).



REPRESENTATION

Appellant represented by:   John S. Berry, Attorney



ATTORNEY FOR THE BOARD

B. Thomas Knope, Counsel



INTRODUCTION

The Veteran served on active duty from August 1979 to August 1992.

This matter is on appeal from rating decisions in September 2009, August 2010, September 2011, May 2013, August 2013, August 2014 and April 2015 by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska.

This appeal is comprised entirely of documents contained in the Virtual VA paperless claims processing system as well as the Veterans Benefits Management System (VBMS).  Accordingly, any future documents should be incorporated in the Veteran's VBMS file.

The issues of entitlement to service connection for bilateral hearing loss, tinnitus, TDIU, educational benefits, and SMC based on housebound status is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ.



FINDINGS OF FACT

1. On April 19, 2012, the RO received the Veteran's claim seeking entitlement to service connection for a scar on the left knee, and there is no communications prior to this date reflecting the intent to file a claim.

2. The Veteran's psychiatric symptoms have been characterized by avoidance, irritability and some insomnia; occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to symptoms such as suicidal ideation, obsessional rituals which interfere with routine activities, impaired impulse control, near-continuous panic or depression affecting ability to function independently, appropriately and effectively, spatial disorientation, speech that is intermittently illogical, obscure, or irrelevant, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships, have not been shown.

3. The Veteran's right knee disability was characterized by pain and some limitation of motion; limitation of flexion to 30 degrees, limitation of extension to 15 degrees, a combination of limitation of flexion and limitation of extension, favorable ankylosis of the knee at full extension or in slight flexion between 0 and 10 degrees, instability or locking episodes has not been shown.

4. The residuals of the Veteran's total left knee replacement have been characterized by pain and some difficulty walking; severe painful motion or weakness in the affected extremity, ankylosis of the knee in flexion between 10 and 20 degrees, limitation of extension to 30 degrees or nonunion of the tibia and fibula, with loose motion, requiring a brace, has not been shown.

5. The scars to the Veteran's knees were considered to be small, although some pain was noted in the scar on the left knee; scars that were deep and nonlinear and an area or areas of at least 6 sq. in. (39 sq. cm) but less than 12 sq. in., superficial and nonlinear, and of an area of 144 sq. in. (929 sq. cm) or greater, or unstable have not been shown.

6. The anatomical loss or loss of use of one or more creative organs, one foot, one hand or both buttocks, blindness of one eye, having only light perception, complete organic aphonia with constant inability to communicate by speech, deafness of both ears, having absence of air and bone conduction, or the anatomical loss of 25 percent or more of tissue from a single breast or both breasts in combination (including loss by mastectomy or partial mastectomy) or has received radiation treatment of breast tissue, has not been shown.

7. In an August 2004 rating decision, the claims of entitlement to service connection for carpal tunnel syndrome, a right shoulder disorder, back disorder and obesity were was denied on the basis that none of them were shown during active duty service or for many years thereafter and are not related to service or to a service-connected  disability.

8. The evidence added to the record since the August 2004 decision became final is not related to an unestablished fact that is necessary to substantiate the claims of service connection for carpal tunnel syndrome, a right shoulder disorder and a back disorder, but not for obesity.

9. Hypercholesterolemia, obesity and irregular blood sugars are not disorders for which service connection may be granted.

10. Carpal tunnel syndrome, a gastrointestinal disorder, respiratory disorder, hypertension and a hernia were not shown during active duty service and are not related to service.

11. It is at least as likely as not that the Veteran's back disorder, right shoulder disorder and eye disorder are related to active duty service or a service-connected disability.



CONCLUSIONS OF LAW

1. The criteria for the assignment of an effective date prior to November 4, 2011, for the grant of service connection for scars on the left knee, have not been met.  38 U.S.C.A. §§ 1502, 1521, 5103, 5103A, 5110(a) (West 2014 & Supp. 2015); 38 C.F.R. §§ 3.1(r), 3.350, 3.351, 3.352, 3.400 (2015).

2. The criteria for a rating in excess of 50 percent for an acquired psychiatric disorder have not been met.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014 & Supp. 2015); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9411 (2015).

3. The criteria for a rating in excess of 10 percent for a right knee disability based on limitation of motion have not been met.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014 & Supp. 2015); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71, 4.7 l a, DCs 5003, 5256, 5260 (2015).

4. The criteria for a rating in excess of 30 percent for residuals of a left knee disability, status post total knee replacement, have not been met.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014 & Supp. 2015); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71, 4.7la, DC 5055 (2015).

5. The criteria for a compensable rating for a scar to the right knee have not been met.  38 U.S.C.A. §§ 1155, 5107(b) (West 2014 & Supp. 2015); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.14, 4.118, DC 7801, 7802, 7804 (2015).

6. The criteria for a 10 percent rating, but no more, for a scar to the left knee have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014 & Supp. 2015); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.14, 4.118, DC 7801, 7802, 7804 (2015).

7. The August 2004 rating decision that denied the Veteran's claim for entitlement to service connection for carpal tunnel syndrome, a right shoulder disorder, back disorder and obesity is final.  38 U.S.C.A. § 7105 (West 2014 & Supp. 2105); 38 C.F.R. § 20.1103 (2015).

8. As the evidence received subsequent to the August 2004 rating decision is new and material, the requirements to reopen the claims for entitlement to service connection for carpal tunnel syndrome, a back disorder and a right shoulder disorder have been met.  38 U.S.C.A. §§ 5108, 7105 (West 2014 & Supp. 2015); 38 C.F.R. § 3.102, 3.156 (2015).

9. As the evidence received subsequent to the August 2004 rating decision is not new and material, the requirements to reopen the claim for entitlement to service connection for obesity have not been met.  38 U.S.C.A. §§ 5108, 7105 (West 2014 & Supp. 2015); 38 C.F.R. § 3.102, 3.156 (2015).

10. The criteria for entitlement to service connection for carpal tunnel syndrome, a gastrointestinal disorder, respiratory disorder, hypertension, residuals of a hernia surgery, obesity, hypercholesterolemia and irregular blood sugar levels, have not been met.  38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2014 & Supp. 2015); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2015).

11. The criteria for entitlement to service connection for a back disorder, a right shoulder disorder, and an eye disorder have been met.  38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2014 & Supp. 2015); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2015).



REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Effective Dates

In general, the effective date for the grant of service connection based upon an original claim or a claim reopened after final disallowance is either the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service; otherwise it will be the date of receipt of the claim or the date entitlement arose, whichever is the later.  38 U.S.C.A.  § 5110(b)(l) (West 2014 & Supp. 2015); 38 C.F.R. § 3.400(b) (2015).

For effective date purposes, a claim is a formal or informal written communication identifying and requesting a determination of entitlement or evidencing a belief in entitlement, to a benefit.  38 C.F.R. § 3.l (p) (2014).  Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, her or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris, may be considered an informal claim.  Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution.  If received within one year after the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155 (2014); Norris v. West, 12 Vet. App. 413, 421 (1999).

In this case, the Veteran submitted a claim on April 19, 2012, seeking entitlement to service connection for a scar to the left knee.  In a May 2014 decision, she was granted service connection for this disorder, effective November 4, 2011.  As an initial matter, the Board determines that April 9, 2012, is the date of the Veteran's formal claim.

Notably, the evidence does not indicate that she has ever filed a claim prior to this date, nor has she asserted that she has submitted such a claim before this date.
Therefore, the Board finds that, for effective date purposes, this is the date of receipt for the Veteran's claim of entitlement to service connection for a scar to the left knee.

The date of receipt of the claim having been established, the Board has also reviewed whether there is any evidence of an intent to file a claim for benefits prior to April 19, 2012.  In this regard, a review of the record fails to show that the RO received claim or informal written communication indicative of the Veteran's desire to seek service connection for a scar to the left knee.  Indeed, according to the May 2014 rating decision, the assigned effective date was based on when the scar was first clinically observed in the year prior to submitting her claim.  However, this does not constitute an intent to file a claim.  Therefore, the Board concludes that the effective date of the Veteran's service-connected scar on her left knee is no earlier than November 4, 2011, and effective date prior to this is not warranted.

Increased Ratings

Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity.  Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability.  See 38 C.F.R. § 4.1 (2015).  Separate diagnostic codes identify the various disabilities.  38 U.S.C.A. § 1155 (West 2014 & Supp. 2015); 38 C.F.R. Part 4 (2015).  While the Board typically considers only those factors contained wholly in the rating criteria, it is appropriate to consider factors outside the specific rating criteria when appropriate in order to best determine the level of occupational and social impairment.  See Mauerhan v. Principi, 16 Vet. App. 436 (2002); Massey v. Brown, 7 Vet. App. 204, 208 (1994).

Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating.  38 C.F.R. § 4.7 (2015).  When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran.  38 C.F.R. § 4.3 (2015).

Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance.  It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements.

The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion.  Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled.  38 C.F.R. §§ 4.10, 4.40, 4.45
(2015); see also Deluca v. Brown, 8 Vet. App. 202 (1995).  The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups.

Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability.  Thus, actually painful, unstable, or malaligned joints, due to healed injury, are as entitled to at least the minimum compensable rating for the joint.  The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.  See 38 C.F.R. § 4.59 (2015).

Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible.  See Hart v. Mansfield, 21 Vet. App. 505 (2007).

Acquired Psychiatric Disorder

In April 2010, the Veteran submitted a claim for an increased rating for acquired psychiatric disorder, which is currently rated at 50 percent under 38 C.F.R. § 4.130, DC 9435 (addressing unspecified depressive disorders).

In order to warrant the next-higher 70 percent rating, the evidence must show occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; impaired impulse control (such as unprovoked irritability with periods of violence); near-continuous panic or depression affecting ability to function independently, appropriately and effectively; spatial disorientation; speech intermittently illogical, obscure, or irrelevant; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9435 (2015)

After a review of the evidence, the Board determines that a rating in excess of 50 percent is not warranted.  First, the objective symptoms exhibited by the Veteran are not so severe that a rating in excess of 50 percent is warranted.  For example, at a VA examination in July 2010, she stated that she slept 8 hours a night, but felt unable to attend her son's sporting events due to her skin condition.  Upon examination, she appeared cooperative and attentive, and her speech and thought content was normal.  Her intelligence was average and there was no indication of delusions or psychomotor activity.  She did not report panic attacks, nor did she indicate homicidal or suicidal ideation.

Next, at a VA examination in July 2011, the Veteran stated that she gets depressed on bad days, and becomes anxious when going to bed at night.  Upon examination, she appeared neatly groomed and appropriately dressed.  She was cooperative and friendly, and her affect was normal.  Her thought process and content were unremarkable, and there was no evidence of psychomotor activity.  She was oriented to person, place and time.  There was no obsessive or ritualistic behavior, nor were there any suicidal or homicidal thoughts.

At a VA examination in December 2012, the Veteran again appeared well groomed and cooperative.  Her attention and concentration were intact, although she complained of bouts of insomnia.  She did not display symptoms such as flattened affect, impaired judgment, or suicidal ideation.  Finally, at a VA examination in June 2014, the examiner stated that the level of mental health intervention was "light."  Upon examination, she displayed a depressed mood with some chronic sleep impairment.  However, there is no indication that other symptoms such as suicidal ideation, obsessional rituals which interfere with routine activities, impaired impulse control, near-continuous panic or depression affecting ability to function independently, appropriately and effectively have been shown.

Therefore, the Board finds that the Veteran does not exhibit objective symptoms that would be sufficient to warrant a rating in excess of 50 percent.  Indeed, many of these objective symptoms have not been shown.  While it is true that some depression and insomnia was evidence, these symptoms alone are insufficient to warrant an increased rating give the otherwise relatively mild array of symptoms.

Next, although the general rating formula provides specific examples of symptoms that may result from various acquired psychiatric disorders, the Board emphasizes that its analysis should not be limited to only these symptoms, but should also consider any other relevant criteria outside of the rating code in order to determine the level of occupational and social impairment.  Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002).

As such, the Board has also considered the extent to which there are other indications of occupational and social impairment, such as difficulty in adapting to stressful circumstances or the inability to establish and maintain effective relationships that may cause deficiencies in most areas, to include social and occupational  inadaptability.

However, there are no other indications to support a rating in excess of 50 percent. For example, at her VA examination in July 2010, the stated that she had been married for 21 years and have four children together.  She also helps care for her grandchildren.  She routinely attends church events and had previously worked as an aerobics instructor.  At her VA examination in July 2011, she indicated that she shops often (calling herself a "shopaholic") and, while she does not have friends to do social activities with, she does see her family at holiday gatherings.

At a VA examination in December 2012, the VA examiner determined that that the Veteran had "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self­ care and conversation." In November 2013, the Veteran again stated that she had been married to her husband, and also watches her grandchildren on a relatively consistent basis.  Finally, at her VA examination in June 2014, she reported that her relationship with her husband was good, and she sees her grandchildren often.  She also stated that she attends church.

The Board has also considered the Veteran's Global Assessment of Functioning (GAF) score.  The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness.  See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV)).

In this case, the Veteran's GAF scores have ranged from 55 to 60.  A GAF score of 51-60 reflects "moderate" symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or "moderate" difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers).  Here, the symptoms displayed by the Veteran are actually better than the GAF scores assigned.  In any event, there is no basis for an increased rating based on such symptoms.  Therefore, a rating in excess of 50 percent is not warranted.

Right Knee

In a May 2013 rating decision, the Veteran was granted service connection for a right knee disability with a 10 percent rating under 38 C.F.R. § 4.7la, DC 5260 (addressing arthritis and limitation of flexion).  When rating knee claims, a claimant who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257 or 5258/5259.  See VAOPGCPREC 23-97.

For example, when a knee disorder was already rated under DC 5257 (addressing lateral instability), the a separate rating may be warranted if the Veteran's knee also shows limitation of motion which at least meets the criteria for a zero-percent rating under DC 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more).

Moreover, a separate rating could also be warranted under 38 C.F.R. § 4.59, based on X-ray findings of arthritis with painful motion.  See VAOPGCPREC 9-98; see also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997).  In addition, the General Counsel has also held that separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint.   VAOPGCPREC 09-04.

In order to warrant an increased rating in the right knee based solely on limitation of motion, the evidence must show:

• Limitation of flexion to 30 degrees (20 percent under DC 5260);
• Limitation of extension to 15 degrees (20 percent under DC 5261);
• Limitation of flexion to 45 degrees and limitation of extension to 10 degrees (two separate 10 percent ratings under DCs 5260 and 5261, respectively); or
• Favorable ankylosis of the knee at full extension or in slight flexion between 0 and 10 degrees (30 percent under DC 5256).

See 38 C.F.R. § 4.7 la (2015).

After a review of the pertinent evidence, the Board determines that a rating in excess of 10 percent is not warranted for the right knee based on limitation of motion.  Specifically, at a VA examination in December 2012, the Veteran reported that she experienced right knee pain after her left knee surgery, accompanied by some swelling.  Upon examination, she exhibited 130 degrees of flexion and full extension without any additional limitation due to pain.  An orthopedic treatment note from February 2013 noted right knee pain that was made worse after prolonged standing.  On that occasion, she demonstrated weakness and a range of motion limited to 112 degrees of flexion and 3 degrees of extension.  Although she underwent a new VA examination in February 2015, ranges of motion were not measured in the right knee.  Therefore, a rating in excess of 10 percent is not warranted based on limitation of motion.

When considering this rating, the Board has considered the impact of functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness.  38 C.F.R. §§ 4.40, 4.45, 4.59; Del uca v. Brown, 8 Vet. App. 202, 206-7 (1995). In this case, while the Veteran complains of pain in her right knee, it does not appear that her pain results in additional functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 37-43 (2011) (pain must affect some aspect of the normal working movements of the body such as strength, speed, coordination or endurance).  Put another way, while the Veteran has complained of pain, these complaints are adequately contemplated in the ratings she currently receives.

Next, the Board considers whether a separate compensable rating is warranted for the right knee based on instability or cartilage symptoms.  In order to warrant a separate rating for this type of disorder, the evidence must show:

• Removal of the semilunar cartilage with residual symptoms (I0 percent under DC 5259);
• Dislocation of the semilunar cartilage with frequent episodes of "locking," pain and effusion in the joint (20 percent under DC 5258); or
• Recurrent subluxation or lateral instability (under DC 5257; 10 percent for slight symptoms, 20 percent for moderate symptoms, and 30 percent for severe symptoms).

See 38 C.F.R. § 4.7 J a.

However, a separate rating based on limitation of motion is not warranted. Specifically, at VA examinations in December 2012 and February 2015, joint stability testing in the right knee was normal.  Moreover, there has never been an indication of an injury to the semilunar cartilage.  Therefore, based on the evidence of record, a rating in excess of those already assigned for either limitation of motion, instability or injury to the semilunar cartilage.

Left Knee

In December 2014, the Veteran filed a new claim seeking an increased rating for her service-connected left knee disability, characterized by residuals of a total knee replacement, which is currently rated at 30 percent under 38 C.F.R. § 4.7 J a, DC 5055 (addressing prosthetic knee replacements).  In order to warrant a rating in excess of 30 percent, the evidence must show:

• Chronic residuals consisting of severe painful motion or weakness in the affected extremity (60 percent under DC 5055);
• Ankylosis of the knee in flexion between J O and 20 degrees (40 percent under DC 5256);
• Limitation of extension to 30 degrees (40 percent DC 5261); or
• Nonunion of the tibia and fibula, with loose motion, requiring a brace (40 percent under DC 5262).

See 38 C.F.R. § 4.7 J a (2015).

Based on the evidence of record, a rating in excess of 30 percent is not warranted. Specifically, at a VA examination in February 2015, the Veteran stated that she was experiencing left knee pain that would swell after activity.  She participated in physical therapy after her knee replacement, and is currently unable to walk more than I0 minutes at a time.  Upon examination, she exhibited 115 degrees of flexion and full extension.  Ankylosis was specifically noted to be absent.  There was also evidence of pain upon weightbearing and there was no reduction in muscle strength. Based on her own statements made at that time, while there is pain in her knee, she has not indicated that it is of the "severe" type necessary to support an increased evaluation.

X-rays of the knee did not reveal any sort of nonunion of the tibia or fibula, nor is there any sign that the artificial joint was loose.  As would be expected, there was no instability observed.  Therefore, a rating in excess of 30 percent is not warranted.

In the case of both knees, the Board has considered the impact of functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness.  38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995).  In this case, while the Veteran complains of pain in her knees, it does not appear that this pain results in additional functional loss such that an increased rating is warranted.  Put another way, while the Veteran has complained of pain, these complaints are adequately contemplated in the ratings she currently receives.

Scars

The Veteran currently receives noncompensable ratings for the scars on her knees. In order to warrant a compensable rating for a scar to the knee, the evidence must show that the scar is:

• Deep and nonlinear and an area or areas of at least 6 sq. in. (39 sq. cm) but less than 12 sq. in. (77 sq. cm) (10 percent under DC 7801);
• Superficial and nonlinear, and of an area of 144 sq. in. (929 sq. cm) or greater ( l0 percent under DC 7802);
• One or two in number that are unstable or painful (10 percent under DC 7804).

See 38 C.F.R. § 4.118.

A scar is "superficial" when it is not associated with underlying soft tissue damage. Under Note (1) of Diagnostic Code 7804, a scar is considered "unstable" if there is frequent loss of covering of skin over the scar.  If a scar is both unstable and painful, an additional 10 percent will be added to the assigned rating.  Moreover, a scar with a compensable rating based on pain and instability may also warrant a separate rating based on size.  See 38 C.F.R. § 4.118, DC 7804, Note (3).

Based on the evidence of record, a compensable rating is not warranted for the scar on the right knee.  Specifically, at the Veteran's VA examination in December 2012, the examiner noted that the Veteran had a scar on her right knee resulting from an arthroscopic procedure.  As for the scar on the left knee, there is no basis for a compensable rating based size.  As the Veteran herself stated in September 2014, the scar on her left knee was 10 inches long and less than an inch wide.  This is much smaller than what is required for a compensable rating.

However, in her September 2014 statement, she stated that the scar was "sensitive to heat, cold, certain fabrics, creams as well as being numb around some areas of the incision site." In the Board's view, this meets the criteria for "painful," and a 10 percent rating is warranted on this basis.  However, as it is the only scar, a rating in excess of 10 percent is not warranted.

Vitiligo

The Veteran is also seeking an increased rating for her vitiligo, which is currently rated at 80 percent under 38 C.F.R. § 4.118, DC 7800 (addressing disfigurement to the head face or neck).  An 80 percent rating is the highest schedular rating allowable under any diagnostic code within this section.  Therefore a rating in excess of 80 percent is not warranted on a schedular basis.

In considering the appropriate disability ratings, the Board has also considered the Veteran's statements that her service-connected disabilities are worse than the ratings she currently receives.  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.  While the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to her through her senses, she is not competent to identify a specific level of disability of her service-connected disabilities according to the appropriate diagnostic codes.  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").

On the other hand, such competent evidence concerning the nature and extent of the Veteran's service-connected disabilities has been provided by the medical personnel who have examined her during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations.  The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated.

Extraschedular  Considerations

The Board also finds that consideration for an extraschedular evaluation, a component of a claim for an increased rating, is not warranted.  Bagwell v. Brown, 9 Vet. App. 337, 339 (1996).  Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record.  Barringer v. Peake, 22 Vet. App. 242 (2008).

In considering whether an extraschedular rating may be warranted, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology.   If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization.   If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration.  See Thun v. Peake, 22 Vet. App. 111 (2008).

In this case, the evidence does not indicate that Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above.  Specifically, the Board has reviewed all of her relevant symptoms related to the issues on appeal, and concludes that there are no symptoms that were not able to be addressed by the applicable diagnostic codes.  See Mitt/eider v. West, 11 Vet. App.  181 (1998).  As such, the Veteran's symptoms are not which are so unusual that they are outside the schedular criteria.

In this regard, it is important for the Veteran to understand that this finding does not suggest the Veteran does not have problems with her service connected disabilities. The problem with Thes issues are the basis for the current findings.

Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran's disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted.  See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995).

Based on evidence of record, the Board determines that a 10 percent rating for a scar to the Veteran's left knee is warranted.  However, increased ratings are not warranted for any disorder on appeal.  As such, the appeal is denied to this extent.

Special Monthly  Compensation  Based on Loss of Use

The Veteran has also submitted a claim seeking special monthly compensation (SMC) based on loss of use under 38 U.S.C.A. § 1114(k).  SMC is warranted under this section if the veteran, as the result of service-connected disability, has suffered:

• The anatomical loss or loss of use of one or more creative organs;
• or one foot, one hand or both buttocks;
• Blindness of one eye, having only light perception
• Complete organic aphonia with constant inability to communicate by speech;
• Deafness of both ears, having absence of air and bone conduction; or
• The anatomical loss of 25 percent or more of tissue from a single breast or both breasts in combination (including loss by mastectomy or partial mastectomy) or has received radiation treatment of breast tissue.

VA regulations further provide that extremely unfavorable complete ankylosis of the knee, or complete ankylosis of two major joints of an extremity, or shortening of the lower extremity of 3 1/2 inches or more, will constitute loss of use of the foot involved; complete paralysis of the external popliteal nerve (common peroneal) and consequent footdrop, accompanied by characteristic organic changes including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve, will be taken as loss of use of the foot. 38 C.F.R. § 3.350(a) (2) (i) (a) and (b).

Here, however, SMC is not warranted, as none of these conditions has been shown. Of particular note, although it is true that the Veteran has a prosthetic knee, the evidence has not established that ankylosis is present in either knee.  Therefore, as none of the above conditions have been met, SMC is not warranted under 38 U.S.C.A. § 1114(k).

New and Material Evidence

In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material.  If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999); Manio v. Derwinski, 1 Vet. App. 140 (1991).

Under the relevant regulation, "new" evidence is defined as evidence not previously submitted to agency decision-makers.   "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  If it finds that the submitted evidence is new and material, VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the veteran in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999); but see 38 U.S.C.A. § 5103A (eliminates the concept of a well-grounded claim).

The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low, and consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied.  Rather, consideration should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement.  See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010).

Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). However, for the purpose of establishing whether new and material evidence has been received, the credibility of the such evidence is to be presumed unless "patently incredible" See Duran v. Brown, 7 Vet. App. 216 ( 1994); Justus v. Principi, 3 Vet. App. 510, 513 (1992).

In this case the Veteran is claiming entitlement to service connection for a carpal tunnel syndrome, a back disorder, right shoulder disorder and obesity.  These claims were previously denied by the RO in an August 2004 decision on the basis that none of them were shown during active duty service and were not related to service, and none of them are related to a service-connected disability.  She did not appeal that decision, nor did she submit any new and material evidence within a year of receiving it.  See Buie v. Shinseki, 24 Vet. App. 242 (2011).  This represents the last final denial of these claims.

After a review of the evidence submitted since the August 2004 rating decision became final, the Board determines that the claims related to carpal tunnel syndrome, a back disorder and a right shoulder disorder should be reopened.
Specifically, the evidence of record from prior to the last final denial of the claims included the Veteran's service treatment records, as well as VA treatment records from 1999 to 2004.  The evidence also includes VA examinations from May and June 2004.  Since that time, the Veteran has undergone new VA examinations in December 2012, January 2013 and June 2013, all of which contain relevant information regarding the nature and etiology of each of these claims.  Not only is this evidence "new" in that it was not reviewed prior to the last final denial of these claims, but it is also "material," as it addresses an unestablished fact necessary to support the claim.

As for the Veteran's obesity claim, this claim should not be reopened. Specifically, the Veteran has not presented any clinical evidence regarding her weight gain since the last final denial.

While the Veteran has made new statements regarding her obesity, the Board finds that these assertions are effectively duplicative of the statements already included in the claims file and considered in the prior final decisions.  See Reid v. Derwinski, 2 Vet. App. 312, 315 (1992).  The Veteran's statements are thereby not new and material evidence.

Therefore, as evidence that is both "new" and "material" has been submitted, the issues of entitlement to service connection for carpal tunnel syndrome, a back disorder and a right shoulder disorder should be reopened.  However, as no "new" and "material" evidence has been provided regarding the Veteran's obesity, there is no basis to reopen the previously denied claim.

Service Connection

The Veteran is claiming entitlement to service connection for carpal tunnel syndrome, a back disorder, a right shoulder disorder, a gastrointestinal disorder, respiratory disorder, hypertension, residuals of a hernia surgery, an eye disorder, obesity, hypercholesterolemia and irregular blood sugar levels.  Many of these she asserts are secondary to her service-connected vitiligo and acquired psychiatric disorder.

Under the relevant laws and regulations, 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 (West 2014 & Supp. 2015).  Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995).

Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service.  This presumption is rebuttable by affirmative evidence to the contrary.  38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a).  Moreover, for such chronic diseases, an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a); See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2014).

In addition to the regulations cited above, service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service­ connected disease or injury.  38 C.F.R. § 3.310 (2015).  Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated.

Allen v. Brown, 7 Vet. App. 439 (1995).  When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.  Id.

Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection.  38 U.S.C.A. § 1110 (West 2002); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability).  "In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

As an initial matter, the Board determines that service connection for hypercholesterolemia and irregular blood sugars is not warranted, as none of these are actually benefits for which service connection may be granted.  Specifically, it has been VA policy that hypercholesterolemia is a laboratory result and is not a disability per se. 61 Fed. Reg. 20440, 20445 (May 7, 1996).

Carpal Tunnel Syndrome, Respiratory Disorder, Gastrointestinal Disorder, Hernia, and Hypertension

As for the Veteran's claims related to carpal tunnel syndrome, respiratory disorder, gastrointestinal disorder, hernia and hypertension, service connection is also not warranted, based on the evidence of record.  First, the service treatment records do not reflect complaints of, treatment for, or a diagnosis related to any of these disorders on appeal while in service.  Significantly, an Air Force physical examination in August 1995 fails to document any complaints of or observed symptoms related to any of the claimed disorders.

In fact, the post-service evidence does not reflect symptoms related to these disorders for many years after the Veteran left active duty service.  Specifically, while the Veteran did complain of certain hand symptoms such as arthritis in the hands, the first clinical indication of neurological symptoms in the hands was not until March 2003, where she complained of intermittent tingling.  A respiratory disorder was not noted until December 2012, and she was not diagnosed with hypertension until a VA examination in September 2009.  The Veteran indicated that she had abdominal surgery, and was seen for an umbilical hernia in 2002, however, a ventral hernia was not observed until a VA examination in December 2012.  Finally, she did not complain of diarrhea and constipation until 1980.

The Board emphasizes that this first indication of any of these disorders is at least 7 years after she left active duty.  For many of these disorders, the first clinical indication is often well over I 0 years.  As such, a continuity of symptoms is not shown based on the clinical evidence.

As part of this claim, the Board has assessed the credibility and probative weight of all relevant evidence, including the competency and credibility of statements made by the Veteran and others regarding her assertions of symptoms since active duty.
In this regard, while Veteran is competent to discuss the nature of some disorders despite her status as a lay person, she is not competent diagnose disorders like those on appeal, as they may not be diagnosed by its unique and readily identifiable features, and thus requires a determination that is "medical in nature." Jandreau v. Nicholson, 492 F.3d  1372, 1376 (Fed. Cir. 2007).

Nevertheless, the Veteran is competent to testify about the presence of observable symptomatology, which may provide sufficient support for a claim of service connection, if credible, regardless of the lack of contemporaneous medical evidence.  See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994).

However, the Board determines that the Veteran's reported history of continued symptomatology since active service, while competent, is of diminished value in view of other evidence of record.  In making this determination, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant.  Caluza v. Brown, 7 Vet. App. 498 (1995).

Of particular note, the Veteran has submitted a large number of claims for service connection, beginning as early as 1992. However, none of the disorders on appeal were mentioned at that time.  The fact that the Veteran was aware of the VA benefits system, sought out a claim for compensation related to many other disorders, but made no reference to the other disorders she claims now weighs heavily against her credibility.  Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011)(Lance, J., concurring) (discussing the distinction between cases in which there is a complete absence of any evidence to corroborate or contradict the testimony, and cases in which there is evidence that is relevant either because it speaks directly to the issue or allows the Board as factfinder to draw a reasonable inference).  Had the Veteran had these disorders she claims now at the time she filed a claim in 1992, as she now claims, there seems to be no reason why the Veteran would not have identified them at that time.  Therefore, continuity is not established and there is evidence against this finding based on the clinical evidence of record or the Veteran's statements.

Next, service connection may also be granted when the evidence establishes a medical nexus between active duty service and current complaints.  In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran's claimed disorders to active duty, despite her contentions to the contrary. First, as was mentioned previously, the evidence of record does not indicate that  any of these disorders were present during active duty, and none of the subsequent medical evidence reflects a relationship between these disorders are active duty service.  Moreover, no treating physician has opined that such a relationship exists.

As for whether any of these disorders are otherwise related to active duty service or to a service-connected disability, the Board places significant value on the opinions of a VA examiner who evaluated the Veteran's symptoms during the course of the appeal.  Specifically, in a VA examination in January 2013, after a thorough examination, a VA examiner determined that the Veteran's carpal tunnel syndrome, hernia, respiratory disorder and hypertension were all less likely than not related to active duty service.

First, regarding her hernia, the examiner noted that the Veteran did not have any complaints related to this disorder in 2001, and a hernia was not visibly present until 2006.  Moreover, the examiner pointed out that she has undergone a number of post-service procedures that could have influenced the development of a hernia.

When considering the Veteran's carpal tunnel syndrome, the VA examiner in January 2013 noted the Veteran's assertions that this resulted from her lifting tables and moving chairs.  However, the examiner also noted that there were no complaints of such symptoms in service or for many years thereafter.  Therefore, this was less likely than not related to service.

Regarding the Veteran's respiratory complaints, an examiner in December 2012, a VA examiner acknowledged that the Veteran was seen on one occasion for an upper respiratory infection in 1980. However, her current respiratory infection was not related to her service-connected disabilities, as her pulmonary functioning rests were currently normal.  In January 2013, the VA examiner recognized that the Veteran's complaints were asthmatic in nature.  However, while the Veteran asserts that this is due to her joint disabilities, the examiner noted that respiratory disorders and joint disorders are "unrelated medically."

As for the Veteran's hypertension claim, the VA examiner in January 2013 noted that the Veteran was seen for elevated blood pressure.  However, there did not seem to be a correlation between her hypertension and medication she was taken.  To the contrary, her blood pressures had been slowly elevating over the course of a long period of time.  As such, the two were less likely than not related, especially given her family history of hypertension.

Finally, at a VA examination in June 2014, the Veteran stated that her gastrointestinal distress began approximately 4 years before, although later mentioned that she first experienced diarrhea since service.  After a review of the claims file, the examiner determined that the Veteran does not have a chronic gastrointestinal disorder that is related to service, as there is no evidence of in­ service complaints.

The Board finds that these examinations are collectively adequate for evaluation purposes.  Specifically, the examiners reviewed the claims file, interviewed the Veteran, and conducted physical examinations.  There is no indication that the VA examiner was not fully aware of the Veteran's past medical history or that any examiner misstated any relevant fact.

In arriving at this conclusion, the Board has also considered the statements made by the Veteran relating her disorders on appeal to her active service or to a service­ connected disability.  The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when ( I ) a  layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional."  Davidson v. Shinseki, 581 F.3d  1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)).

In this case, however, the Veteran is not competent to provide testimony regarding the etiology of any of the disorders on appeal.  See Jandreau, 492 F.3d at 1377, n.4. Because these disorders are not diagnosed by unique and readily identifiable features, they do not involve a simple identification that a layperson is competent to make.  Therefore, the unsubstantiated statements regarding the claimed etiology of these issues are found to lack competency.

Right Shoulder Disorder, Back Disorder and Eye Disorder

As a final issue, the Board determines that service-connection for a back disorder, right shoulder disorder and eye disorder should be granted.  Specifically, at a VA supplemental examination in June 2013 which was specifically related to these disorders, the VA examiner determined that the Veteran's active duty service, which included moving of chairs and tables, was not the primary cause of her back and right shoulder symptoms.  However, the VA examiner also conceded that these activities "may have been a factor," in the ultimate development of these disorders.

In the Board's view, the fact that the Veteran's active duty service activities have contributed to these disorders is sufficient to warrant service connection, and these claims are granted on this basis.

Regarding the Veteran's eye complaints, it has been the Veteran's assertion that she has experienced severe dry eyes as her service-connected vitiligo has progressed to the point that she requires eye drops multiple times per day.  At a December 2014 VA examination, the examiner concluded that the Veteran's dry eye syndrome was not related to her vitiligo, since "[v]itiligo has not been shown to cause a dry eye syndrome."  While another autoimmune disorder, Sjogren's syndrome, has been known to cause dry eyes, this has not been diagnosed here.

In the Board's view, however, this opinion is in adequate in that the examiner dismisses a relationship between vitiligo and dry eye syndrome without any supporting explanation.  Moreover, recognition is given to the fact that, as the etiology of vitiligo is unclear, the effects of this disease are similarly unclear.  See the MERCK Manual, Section 7, Ch. 85, p. 720, Pigmentation Disorders (19th ed. 2011).  Here, the Board cannot ignore that there is no alternative etiology for her eye symptoms and, given the nature of her symptoms, it is at least as likely as not that this is related to her vitiligo.  Therefore, service connection is also warranted for this disorder.

In conclusion, the Board concludes that service connection is warranted for a right shoulder, back and eye disorder.  However, the Board concludes that the preponderance of the evidence is against the claims for service connection for carpal tunnel syndrome, a gastrointestinal disorder, respiratory disorder, hypertension, residuals of a hernia surgery, hypercholesterolemia and irregular blood sugars, and these appeals are denied.

VA Duty to Notify and Assist

The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA), which includes an enhanced duty on the part of VA to notify a veteran of the information and evidence necessary to substantiate claims for VA benefits.  38 U.S.C.A. §§ 5103, 5103A (West 2014 & Supp 2015); 38 C.F.R. § 3.159 (2015).
The VCAA also redefines the obligations of VA with respect to its statutory duty to assist veterans in the development of their claims. 38 U.S.C.A. §§ 5103, 5103A (West 2014).

Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim.  38 U.S.C.A. § 5103(a) (West 2014 & Supp. 2015); 38 C.F.R. § 3.159(b) (2015); Quartuccio v. Principi, 16 Vet. App. 183 (2002).  Proper notice from VA must inform the claimant of any information and 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.  This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction.  Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004).

In this case, the Veteran was provided notice letters informing him of both her and VA's obligations.  Therefore, additional notice is not required and any defect in notice is not prejudicial.  With respect to the duty to assist, the Board finds that all necessary assistance has been provided to the Veteran.  The Veteran has also been provided with VA examinations.  Upon review of these examination reports, the Board observes that the examiners reviewed the Veteran's past medical history, recorded her current complaints and history, conducted appropriate evaluations and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The VA examination reports are therefore adequate for the purpose of rendering a decision on appeal.  38 C.F.R. § 4.2 (2015); Barr v. Nicholson, 21 Vet. App. 303 (2007).

Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the above-cited claim.  Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002).



ORDER

An effective date prior to November 4, 2011, for the grant of service connection for scars on the left knee is denied.

A rating in excess of 50 percent for an acquired psychiatric disorder is denied.

A rating in excess of 10 percent for a right knee disability based on limitation of motion is denied.

A rating in excess of 30 percent for residuals of a left knee disability, status post total knee replacement, is denied.

A compensable rating for a scar to the right knee is denied.

A 10 percent rating, but no more, for a scar to the left knee is granted, subject to the laws and regulations for the payment of monetary benefits.

New and material evidence having been submitted, the application to reopen a previously denied claim of entitlement to service connection for carpal tunnel syndrome, a back disorder and a right shoulder disorder is granted, and the claims are reopened.

New and material evidence having not been submitted, the application to reopen the claim for entitlement to service connection for obesity is denied.

Service connection for carpal tunnel syndrome, a gastrointestinal disorder, respiratory disorder, hypertension, residuals of a hernia surgery, obesity, hypercholesterolemia and irregular blood sugar levels is denied.

Service connection for a back disorder, a right shoulder disorder an eye disorder is granted.



REMAND

The Board determines that a new VA audiological examination is warranted for the Veteran's claims for bilateral hearing loss and tinnitus.  Specifically, at a VA examination in December 2014, she did not exhibit tonal thresholds in excess of 25 dB at any frequency between 500 and 4000 Hz.  However, as she exhibited speech discrimination scores of 86 and 80 percent in the right and left ear, respectively, hearing loss for purposes of 38 C.F.R. § 3.385 have been met.

After the examination was completed, the examiner determined that it the Veteran's hearing loss was less likely than not related to her active duty service as there was no discernable shift in tonal thresholds between her entrance physical examination in June 1979 and August 1995. However, the Veteran also speculated that this hearing loss may have been related to her reserve service from 1995 until 2000.

Clarification is required as to whether the Veteran experienced any acoustic trauma during her reserve service that may serve as basis for her current hearing loss.  Additionally, the Board notes that the Veteran experienced an in-service episode of bilateral otitis media in March 1988. Clarification is required on this issue as well.

As for the Veteran's claim for TDIU, since the Board has granted service connection for her back, right shoulder and eye disorder, her disability picture has now changed.  As such, it would be prejudicial to evaluate the Veteran's TDIU claim in the first instance.  Therefore, the RO should reevaluate this issue prior to Board consideration

Finally, since the Veteran's claims for SMC based on housebound status and entitlement to education benefits relies in part on her disability ratings, these issues cannot be addressed until the above development has been completed.  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 cannot be rendered unless both are adjudicated).

Accordingly, the case is REMANDED for the following action:

1. Obtain all treatment records from the VA Medical Center in Omaha, Nebraska, since June 2016, as well as from any VA facility from which the Veteran has received treatment.

If the Veteran has received additional private treatment, she should be afforded an appropriate opportunity to submit them.

2. Schedule the Veteran for a VA examination to determine the nature, extent, onset and etiology of her bilateral hearing loss and tinnitus.  The claims file must be provided to the examiner for review.  All indicated studies deemed necessary by the examiner should be performed, and all findings of these tests should be reported in detail.

The examiner should specifically provide opinions as to whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran's bilateral hearing loss and tinnitus, had its onset in, or is otherwise etiologically related to, her active service, her reserve service, or to any medication she takes for her service­ connected disabilities.  The examiner should also discuss functional her audiological symptoms have on her daily living and employment.

The examiner must also consider the Veteran's lay statements regarding her bilateral hearing loss and tinnitus.  If the examiner cannot provide any of the requested opinions without resorting to speculation, he or she should provide an explanation stating why there is so. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s).

3. After the above action is completed, if the claims are not fully granted, a supplemental statement of the case should be issued on the issues of entitlement to service connection for bilateral hearing loss and tinnitus, as well as entitlement to SMC based on housebound status, education benefits and TDIU, and the claims file should be 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).



JOHN J. CROWLEY
Veterans Law Judge, Board of Veterans' Appeals