Citation Nr: 1754052 Decision Date: 11/28/17 Archive Date: 12/07/17 DOCKET NO. 11-06 612 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an increased rating in excess of 10 percent for the service-connected gastreoesophageal reflux disease (GERD). 2. Entitlement to an increased rating in excess of 50 percent for the service-connected anxiety disorder. 3. Whether new and material evidence has been received to reopen the claim for service connection for a left leg disability. 4. Whether new and material evidence has been received to reopen the claim for service connection for a dental condition, to include as secondary to GERD. 5. Whether new and material evidence has been received to reopen the claim for entitlement to service connection for headaches. 6. Entitlement to service connection for a left leg disability, other than varicose veins and left lower leg radiculopathy. 7. Entitlement to service connection for a dental condition for compensation benefits. 8. Entitlement to service connection for headaches. 9. Entitlement to an increased rating in excess of 10 percent for degenerative joint disease of the lumbar spine, to include invertebral disc syndrome. 10. Entitlement to an increased rating in excess of 10 percent for the service-connected varicose veins of the left leg. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Erin J. Carroll, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Air Force from June 1984 to August 1989, from November 1992 to March 2000, and from May 2003 to May 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2010 and October 2013 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The March 2010 rating decision continued the 30 percent disability rating assigned to the service-connected anxiety disorder, while also denying a rating in excess of 10 percent for GERD and declining to reopen the claims for entitlement to service connection for a left leg disability. However, an August 2010 rating decision granted a 50 percent disability rating for the service-connected anxiety disorder effective April 12, 2010. The October 2013 rating decision continued the 10 percent rating for the service-connected lower back disability, while also declining to reopen the claims for entitlement to service connection for a dental condition and migraines. Service connection may be awarded for dental conditions for (1) compensation benefits, or (2) outpatient dental treatment purposes. Claims for outpatient dental treatment submitted to VBA should be referred to the Veterans Health Administration (VHA) for preparation of a dental treatment rating. See also 38 C.F.R. § 3.381 (2017). Included in the Veteran's claim for service connection due to dental trauma is a claim for service connection for outpatient dental treatment purposes. See Mays v. Brown, 5 Vet. App. 302 (1993) (any claim for service connection for a dental condition is also a claim for VA outpatient dental treatment). The Board lacks jurisdiction over that claim, as the RO (i.e., VBA) has only adjudicated the issue of entitlement to service connection for a dental condition. The RO should refer the inferred claim for dental treatment purposes to VHA for appropriate action, if such has not been done already. The issues of entitlement to service connection for headaches, as well as for increased ratings for the lumbar spine disability and left leg varicose veins are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's GERD is characterized by persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation that is accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 2. Throughout the period on appeal, the Veteran's service-connected anxiety disorder has been productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as panic attacks and difficulty in establishing and maintaining effective work and social relationships. 3. The RO previously denied the Veteran's claim for entitlement to service connection for a left leg disability in an unappealed September 2006 rating decision. 4. The evidence received since the September 2006 rating decision regarding the claim for service connection for a left leg disability is 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 raises a reasonable possibility of substantiating the claim for service connection on the merits. 5. The RO previously denied the Veteran's claim for entitlement to service connection for a dental condition in an unappealed March 2010 rating decision. 6. The evidence received since the March 2010 rating decision regarding the claim for service connection for a dental condition is 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 raises a reasonable possibility of substantiating the claim for service connection on the merits. 7. The RO previously denied the Veteran's claim for entitlement to service connection for headaches in an unappealed March 2010 rating decision. 8. The evidence received since the March 2010 rating decision regarding the claim for service connection for headaches is 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 raises a reasonable possibility of substantiating the claim for service connection on the merits. 9. The Veteran does not have a current diagnosis of a left leg disability. 10. The Veteran does not have dental condition for which compensation may be granted, nor does she have a dental condition or disability as a result of trauma during her active military service. CONCLUSIONS OF LAW 1. The criteria for an increased rating to 30 percent, but no higher, for GERD have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7346 (2017). 2. For the period on appeal, the criteria for a rating in excess of 50 percent for the service-connected anxiety disorder have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 3. The September 2006 rating decision denying the Veteran's claim for service connection for a left leg disability is final. 38 U.S.C.A. §§ 5108, 7105 (West 2014); 38 C.F.R. § 20.1103 (2017). 4. As new and material evidence has been received, the claim for entitlement to service connection for a left leg disability is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 5. The March 2010 rating decision denying the Veteran's claim for service connection for a dental condition is final. 38 U.S.C.A. §§ 5108, 7105 (West 2014); 38 C.F.R. § 20.1103 (2017). 6. As new and material evidence has been received, the claim for entitlement to service connection for a dental condition is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 7. The March 2010 rating decision denying the Veteran's claim for service connection for headaches is final. 38 U.S.C.A. §§ 5108, 7105 (West 2014); 38 C.F.R. § 20.1103 (2017). 8. As new and material evidence has been received, the claim for entitlement to service connection for headaches is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 9. The criteria for entitlement to service connection for a left leg disability have not been met. 38 U.S.C.A. §§ 1101, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 10. The criteria for service connection for a dental disorder for purposes of compensation have not been met. 38 U.S.C.A, §§ 1110, 1721, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.381, 4.150, 17.161 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Entitlement to Increased Ratings Disability ratings are assigned under a schedule for rating disabilities and based on a comparison of the veteran's symptoms to the criteria in the rating schedule. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2017). Disability evaluations are determined by assessing the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the ratings schedule. Individual disabilities are assigned separate Diagnostic Codes, and ratings are based on the average impairment of earning capacity. See 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2017). If there is a question as to which evaluation should be applied to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Further, in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2017). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as here, 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. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, a staged rating is warranted if the evidence demonstrates distinct periods of time in which a service-connected disability exhibited diverse symptoms meeting the criteria for different ratings throughout the course of the appeal. Fenderson v. West, 12 Vet. App, 119, 125-126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Secretary shall give the benefit of the doubt to the Veteran when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). A. GERD Service connection for the Veteran's GERD was granted in a September 2006 rating decision, at which time a 10 percent rating was assigned effective May 31, 2006. In April 2009, the Veteran filed a claim for an increased rating, which the RO denied in a March 2010 rating decision. The Veteran filed a notice of disagreement in April 2010, after which the RO issued a statement of the case in December 2010. The Veteran's GERD is rated under Diagnostic Code 7399-7346. Under DC 7346, a 10 percent rating is warranted for two or more of the symptoms from the criteria for a 30 percent rating, but of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation accompanied by substernal or arm or shoulder pain and productive of considerable impairment of health. Symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia or other symptom combinations productive of severe impairment of health equate to the highest rating of 60 percent. 38 C.F.R. § 4.114, Diagnostic Code 7346. The Board notes that post-service VA treatment records indicate that the Veteran reported experiencing acid reflux. In November 2009, the Veteran's husband submitted a statement that indicated that the Veteran experienced more frequent and prolonged episodes of acid reflux, as well as some weight loss. Additionally, in March 2010, the Veteran stated that her acid reflux resulted in a loss of appetite, which had caused her to lose between 20 and 25 pounds. In August 2010, the Veteran was afforded a VA examination to evaluate the severity of her service-connected GERD. She reported reflux occurring two to three times per week, as well as occasional nausea. She also experienced frequent burning mid-epigastric pain that radiated through the sternum, which ranged from moderate to severe, and was caused by almost anything she ate. She denied experiencing dysphagia, hematemesis, melena, or radiation to the arm. The examiner noted that there was no history of dilatation, esophageal trauma, hospitalization, or esophageal surgery. The Veteran also indicated that her reflux affected her ability to sleep. Most recently, in August 2015, the Veteran underwent a second VA examination for her service-connected GERD. She reported experiencing reflux as a result of eating certain foods, which she avoided, as well as eating infrequently. The examiner noted that continuous medication was used to treat the diagnosed condition. The examination report also indicated persistently recurrent and infrequent episodes of epigastric distress, dysphagia, pyrosis, reflux, and regurgitation. There was no evidence of an esophageal stricture, spasms of the esophagus or an acquired diverticulum of the esophagus. The Veteran's GERD is also shown to cause extensive dental problems. Indeed, a January 2013 private opinion letter reported that the Veteran had undergone extensive dental treatment, including fillings, extractions, root canals, a re-cemented crown, and the implantation of a bridge. The examiner further indicated that the Veteran's history of GERD had caused her teeth to deteriorate at an increasing rate. In March 2016, the Veteran was afforded a VA dental examination. The examination report noted that the Veteran had been diagnosed with severe dental caries of maxillary and mandibular teeth secondary to GERD, resulting in the removal of multiple teeth. After considering the totality of the record, the Board finds the Veteran's GERD manifests in symptoms that most closely approximate those contemplated by a 30 percent rating. As noted above, an August 2015 VA examiner noted that the Veteran experiences persistently recurrent episodes of epigastric distress, dysphagia, pyrosis and regurgitation. At times during the appeal period, she has complained of pain radiating through the sternum, noted in August 2010 as moderate to severe, caused by almost anything she ate. Her disability also has been medically shown to cause deterioration of the teeth, manifesting in extensive dental treatment, the removal of many teeth. Resolving all doubt in favor of the Veteran, the Board finds that the Veteran's GERD is productive of considerable impairment of health, warranting an increased rating to 30 percent. Although the Veteran's gastrointestinal disability has resulted in symptoms of pain, vomiting, some weight loss, there is no evidence of GERD causing hematemesis or melena with moderate anemia, or other symptom combinations productive of "severe" impairment of health, warranting an increased rating to 60 percent under Diagnostic Code 7346. Laboratory tests were administered in September 2015, and no significant results were reported. The September 2015 examiner pertinently indicated the GERD had no functional impact on the Veteran's ability to work, and did not note any other findings indicative of additional impairment of health. Both the September 2015 examiner and the Veteran attributed the recent increase in her symptoms to being out of her usual routine during a trip. See September 2015 VA examination report. Thus, a disability rating in excess of 30 percent is denied for the period on appeal. In sum, an increased rating to 30 percent, but no higher, for service-connected GERD is granted. B. Anxiety Disorder Service connection was originally established for an anxiety disorder in a September 2006 rating decision, which assigned a 30 percent evaluation pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9400, effective May 31, 2006. The rating was increased to 50 percent effective April 12, 2010, in an August 2010 rating decision. Pursuant to the General Rating Formula for Mental Disorders, a 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9400 (2017). A 70 percent evaluation contemplates occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activity; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships. Id. Lastly, a 100 percent evaluation is warranted where there is total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or name. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126 (b). Historically, psychiatric examinations frequently included assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF scores are 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). While not determinative, a GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). According to the GAF scale, a score within the range of 61 to 70 represents mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational or school functioning (e.g., few friends, conflicts with peers or coworkers). A score within the range of 51 to 60 represents 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). A score of 41 to 50 reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score between 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). The Board notes that the GAF Scale has been abandoned in the updated fifth edition of the DSM. In this case, however, the DSM-IV was in use at the time the medical entries of record were made. Thus, the GAF scores assigned remain relevant for consideration in this appeal. The evidence in this case pertinent to the claim for an increased rating includes lay statements submitted in support of the Veteran's claim, VA treatment records, and several VA examination reports. The mental health records associated with the Veteran's treatment are voluminous. The Board notes that it has reviewed the evidence in its entirety, but will not be discussing all of it with specificity. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (the Board is presumed to have considered all evidence presented in the record; it is not required to specifically discuss every piece of evidence). Post-service VA mental health treatment records between March 2009 and May 2016 have primarily documented the Veteran's reports of experiencing panic attacks, insomnia, depression, anxiety, nightmares, intrusive thoughts, detachment and avoidance behaviors, hypervigilance, and an exaggerated startle response. Notably, in July 2010 and February 2016, she reported obsessive compulsive behaviors, primarily involving germs and cleaning habits. Additionally, in September 2011, the Veteran described an incident in which she lashed out at her son when she became angry. Treatment providers noted that she occasionally demonstrated a tearful and anxious mood during appointments. The Veteran's GAF scores ranged between 50 and 60 throughout this period of time. Most recently, VA treatment records indicate that the Veteran withdrew from school, due to multiple life stressors. In May 2009, the Veteran was afforded a VA examination to evaluate the severity of her anxiety disorder. She reported experiencing panic attacks and ritualistic behavior while driving. She also stated that she had developed obsessive compulsions related to cleaning. She had been married to her husband for 23 years and described their relationship as positive and supportive. She was able to perform activities of daily living independently and manage her own finances. She was involved with training at Fort Jackson, but described having some concentration difficulties there. The examiner noted that the Veteran was alert, logical, and oriented, with adequate insight and normal speech and memory abilities. Notably, her affect was blunted and she was tearful throughout the examination. She reported symptoms including mild dysphoria, insomnia, compulsive rituals, rumination, frequent crying, variable appetite, weight loss, irritability, and panic attacks. She denied depression, homicidal ideation, and suicidal ideation. She was assigned a GAF score of 48. The examiner opined that she had a moderate to severe degree of impairment in social and occupational functioning. In November 2009, the Veteran's husband submitted a statement in which he indicated that she was subjected to a hostile work environment at Fort Jackson, which contributed to her anxiety disorder. In a March 2010 statement, the Veteran contended that she experienced near-continuous panic attacks that affected her ability to function independently, as well as mood swings. She also stated that she experienced a significant amount of stress at work. In June 2010, the Veteran underwent a second VA psychological examination. She reported symptoms including weekly panic attacks, nightmares, poor sleep, and obsessive thoughts. She had been employed at Fort Jackson for the past three years, where she maintained records and assisted with training. She was able to perform activities of daily living independently and manage her finances. She denied any suicidal ideation. The examiner noted that the Veteran was appropriately dressed and maintained good eye contact. She was cooperative and demonstrated appropriate behavior, normal thought processes, normal orientation, as well as normal insight and judgment. Her speech was somewhat pressured and there was some psychomotor agitation present in her movements. The examiner noted some impairment in short term memory and concentration. Additionally, the Veteran was tearful throughout the examination and her mood was dysphoric and anxious. She was assigned a GAF score of 45. Records obtained from the Social Security Administration documented the Veteran's reports of maintaining monthly contact with her mother, sister, and friends. She further indicated that she had good relationships with her neighbors and often checked in on her elderly neighbors. She also reported occasional irritability and a dislike of crowds. The most recent VA psychological examination was conducted in August 2015. The Veteran stated that she was attending school and studying psychology at that time. She reported symptoms including depression, anxiety, panic attacks that occurred weekly or less, sleep impairment, mild memory loss, flattened affect, disturbances of mood or motivation, difficulty in establishing and maintaining effective work and social relationships, as well as difficulty in adapting to stressful circumstances. She was capable of managing her own financial affairs. The examiner noted that the Veteran was well groomed, with coherent speech and linear thought processes. There was no evidence of delusions. However, she was tearful throughout the examination. The Board does not find that a rating in excess of 50 percent for anxiety disorder is warranted, as the evidence of record does not more nearly approximate the criteria for the next higher 70 percent rating at any time during the appeal period. The Board acknowledges the Veteran's reported symptomatology, to include anxiety; panic attacks; sleep impairment; compulsive behaviors; memory and concentration difficulties; depression; avoidance behaviors; and hypervigilance. However, the evidence does not indicate that the panic attacks occur on a near-continuous basis or affect her ability to function independently, as she has consistently been noted as being able to manage activities of daily living on an independent basis. Furthermore, the obsessive thoughts and rituals do not appear to interfere with routine activities, as they are reported to occur in isolated situations, such as driving and cleaning. Although she was assigned GAF scores of 45 and 48 on two occasions during this period (indicative of serious symptomatology), such does not appear congruent with the overall disability picture shown by the Veteran's own lay statements and treatment reports described above, including her primary GAF range between 50 to 60. In terms of social and occupational functioning, the Veteran has reported having a positive relationship with her husband of over 20 years. She has also stated that she worked for several years at Fort Jackson and attended school to study psychology, before recently withdrawing. The evidence further indicates that she maintains relationships with her mother, sister, friends, and neighbors. Although the Veteran's husband indicated that she was subjected to a hostile work environment, a February 2011 VA treatment record documented the Veteran's reports of having supportive friends at work. Thus, although examiners have indicated that she has moderate to severe impairment in social and occupational functioning, as well as difficulty establishing and maintaining effective social and work relationships, the evidence does not suggest that she experiences an inability to establish and maintain these relationships. In addition to the foregoing, there is no evidence of suicidal ideation, as the Veteran has consistently denied suicidal ideation; no evidence of impaired impulse control, which was consistently noted in treatment records to be good; no evidence of spatial disorientation, as the Veteran was consistently noted to be fully oriented during mental status evaluations; no evidence of intermittently illogical or obscure speech, as treated providers consistently noted her speech to be within normal limits, though occasionally pressured; and no evidence of neglect of personal appearance and hygiene, as the Veteran was consistently reported to be well groomed and dressed. The Board does note that the Veteran was occasionally noted to be tearful during the evaluations discussed above. However, the treatment providers and examiners did not suggest that the level of depression was so severe as to prohibit her from properly managing activities of daily living and, while the Board acknowledges that the Veteran reported one instance of an angry outburst towards her son in September 2011, there is no indication that she demonstrated unprovoked irritability with periods of violence, especially to a degree that would warrant a 70 percent rating. The Board has also considered whether the Veteran's symptoms warrant a 100 percent rating for anxiety disorder. However, the evidence of record does not reflect any indication of gross impairment in thought processes, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting herself or others, disorientation to time and place, an inability to perform activities of daily living, or severe memory loss. On the contrary, post-service treatment records indicate the Veteran displayed normal orientation and thought processes. She demonstrated slight short term memory capabilities, but there was no indication that she could not remember her own name or occupation, or the names of relatives. There are no reports of delusions or hallucinations, nor have there been reports of persistent violence or indications of inappropriate behavior. Additionally, the evidence indicates that the Veteran consistently cares for herself and her family on a daily basis. Thus, the Board finds that a 100 percent rating is not warranted in this instance. In sum, there is no basis for a higher evaluation for the Veteran's service-connected anxiety disorder. In reaching the above decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine does not apply. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. New and Material Evidence VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of the claimant. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). For applications to reopen filed after August 29, 2001, as in this case, new and material evidence means evidence not previously submitted to agency decisionmakers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is 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 which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, "credibility" of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The United States Court of Appeals for Veterans Claims (Court) has held that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Even if the RO reopens a claim, the Board must address the question of whether new and material evidence to reopen the claim has been received because the issue goes to the Board's jurisdiction to reach the underlying claim and adjudicate it on a de novo basis. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). In other words, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). A. Left Leg Disability The RO last denied the Veteran's claim of entitlement to service connection for a left leg disability in a September 2006 rating decision. At that time, the pertinent evidence of record included the service treatment records, which failed to show any treatment or diagnosis related to a left leg condition. In its September 2006 rating decision, the RO denied the claim based in large part on the lack of a diagnosis of a disabling condition, other than her service-connected varicose veins, for which compensation could be established. The Veteran was notified of the September 2006 rating decision and did not appeal it, nor did she submit additional evidence within one year of that decision in support of her claim for a left leg disability. As such, the RO's September 2006 rating decision became final. See 38 U.S.C.A. § 7105 (c); 38 C.F.R. §§ 3.156(b), 20.1103. In this case, the newly submitted evidence pertaining to the Veteran's left leg disability consists, in part, of post-service VA treatment records, which indicated that the Veteran reported experiencing additional leg pain. See March 4, 2009 VA treatment record. The Board finds that these complaints are relevant to the question of whether the Veteran has a left leg disability, separate and distinct from her service-connected left leg disabilities. The evidence is new, material and serves to reopen the claim. B. Dental Condition The RO last denied the Veteran's claim of entitlement to service connection for a dental condition in a March 2010 rating decision. At that time, the pertinent evidence of record included the private medical treatment records, which failed to show a loss of teeth due to major trauma during military service. In its March 2010 rating decision, the RO denied the claim based in large part on the lack of a disabling condition for which compensation could be established. The Veteran was notified of the March 2010 rating decision and did not appeal it, nor did she submit additional evidence within one year of that decision in support of her claim for a dental condition. As such, the RO's March 2010 rating decision became final. See 38 U.S.C.A. § 7105 (c); 38 C.F.R. §§ 3.156(b), 20.1103. In this case, the newly submitted evidence pertaining to the Veteran's dental condition consists, in part, of a January 2013 private medical opinion letter and a March 2016 VA examination report, which both indicate that the Veteran's dental condition is due to her service-connected GERD. The Board finds that this relates to an open medical question as to whether the Veteran has a dental condition that is secondary to a service-connected disability. The evidence is new, material and serves to reopen the claim. C. Headaches The Board notes that in the June 2016 statement of the case, the RO reopened the claim for service connection for headaches. Regardless of what the RO has done, the Board must address the question of whether new and material evidence to reopen the claim has been received because the issue goes to the Board's jurisdiction to reach the underlying claim and adjudicate it on a de novo basis. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). In other words, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). The RO last denied the Veteran's claim of entitlement to service connection for headaches in a March 2010 rating decision. At that time, the pertinent evidence of record included the Veteran's service treatment records, post-service VA treatment records, and private medical treatment records, all of which failed to show a diagnosis of or treatment for headaches. In its March 2010 rating decision, the RO denied the claim based in large part on the lack of a diagnosis of a disabling condition for which compensation could be established. The Veteran was notified of the March 2010 rating decision and did not appeal it, nor did she submit additional evidence within one year of that decision in support of her claim for headaches. As such, the RO's March 2010 rating decision became final. See 38 U.S.C.A. § 7105 (c); 38 C.F.R. §§ 3.156(b), 20.1103. In this case, the newly submitted evidence pertaining to the Veteran's headaches consists, in part, of a September 2013 VA examination report, which noted a diagnosis of tension headache. The Board finds that this relates to the medical question as to whether the Veteran has a current headache disability. The evidence is new, material and serves to reopen the claim. IV. Entitlement to Service Connection The Board has reopened all three service-connection claims on appeal. Review of the prior adjudications of record during the appeal period demonstrates that the RO reopened and readjudicated each claim on its merits. As such, the Board may proceed with a merits adjudication as to each issue without a remand for initial adjudication by the RO, barring a need for additional procedural or evidentiary development. Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a) (2016). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). As a general matter, service connection for a disability requires evidence of: "(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 - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). 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. 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. The Board must consider all the evidence of record and make appropriate determinations of competency, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence concerning onset and a history of symptoms during or after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; See Gilbert, supra. A. Left Leg Disability Service treatment records and post-service treatment records are silent for any treatment or diagnoses related to a left leg disability, other than that related to the currently service-connected varicose veins of the left leg and left lower extremity radiculopathy. Although the Veteran did occasionally complain of leg pain, there is no indication that such complaints were ever attributed to a separate diagnosis other than varicose veins and radiculopathy. In July 2006, the Veteran underwent a VA examination for her joints. She did not report, nor did the examiner observe any symptomatology or diagnoses related to the left leg. In January 2015, the Veteran was afforded a VA examination for her service-connected varicose veins. At that time, the examiner did not indicate that the Veteran's symptomatology was attributable to any diagnosis other than varicose veins. Although the Veteran may have experienced left leg pain, the evidence shows no current diagnosis other than the already service-connected varicose veins or radiculopathy. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (service connection requires a current disability). A current disability is one shown at some time during the period beginning proximate to the date of claim. Romanowsky v. Shinseki, 26 Vet. App. 303 (2013). In this case, there is no evidence of a diagnosis of a left leg disability during service, after service, or throughout the current appeal period. Although left leg pain was documented in the Veteran's service treatment records, such symptomatology has been associated with her diagnosis of varicose veins or radiculopathy. Furthermore, the January 2015 VA examiner did not identify any other diagnoses related to the left leg. The Veteran has not reported any pertinent symptomatology or treatment during the current appeal indicative of a separately identifiable leg disability, nor has the objective medical evidence identified a leg disability separate and distinct from her service-connected varicose veins and radiculopathy. Although the Veteran is competent to report observable complaints such as leg pain, she is not competent to provide a diagnosis to account for such complaints. Rather this question requires medical expertise due to the complex nature of the musculoskeletal system. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the preponderance of the evidence is against service connection for a left leg disability. Reasonable doubt does not arise, and the benefit-of-the-doubt doctrine does not apply; the Veteran's claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. B. Dental Condition The Veteran's service treatment records noted recurrent tooth decay, multiple fillings, and the implantation of a crown. In September 2005, the Veteran reported a chipped tooth near the gum line, which was diagnosed as a cavitated carious lesion. Other post-service evidence, to include VA outpatient treatment reports, shows no evidence of dental damage due to in-service trauma. A January 2013 private opinion letter reported that the Veteran had undergone extensive dental treatment, including fillings, extractions, root canals, a recemented crown, and the implantation of a bridge. The examiner further indicated that the Veteran's history of GERD had caused her teeth to deteriorate at an increasing rate. In March 2016, the Veteran was afforded a VA dental examination. The examination report noted that there was no evidence of mandible or maxilla bone loss, bone injury resulting in the loss of teeth, an injury related to the mouth, lips or tongue, osteomyelitis, osteoradionecrosis or bisphosphonate-related osteonecrosis of the jaw, tumors or neoplasms, or disfiguring scars. The examiner noted that, in 2004, the Veteran had been diagnosed with severe dental caries of maxillary and mandibular teeth secondary to GERD, resulting in the removal of multiple teeth. However, there were no findings of loss of the substance of the body of the maxilla or mandible related to trauma or disease, such as due to osteomyelitis. Service connection for a dental claim under compensation purposes can be established only for the specific types of dental and oral conditions listed under 38 C.F.R. § 4.150 (2017), such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. Compensation is available for loss of teeth only if due to loss of substance of the body of the maxilla or mandible. See Simmington v. West, 11 Vet. App. 41 (1998). For loss of teeth, bone loss through trauma or disease such as due to osteomyelitis must be shown for purposes of compensability. The loss of the alveolar process as a result of periodontal disease is not considered disabling. See Note to Diagnostic Code 9913, 38 C.F.R. § 4.150. Based on the evidence of record, service connection is not warranted under 38 C.F.R. § 4.150, as there is no indication that the Veteran's claimed disorder involves impairment to the mandible or bone loss in the maxilla or mandible region. She has never asserted nor does the evidence show actual bone loss or other maxillary impairment that causes her to lose her teeth, nor has any treatment record indicated such impairment. The Board notes the in-service report of a chipped tooth, as well as the positive opinions connecting the Veteran's dental issues to her service-connected GERD. However, there is no indication that her dental issues were related to the occurrence of in-service dental trauma, that her chipped tooth or post-service dental issues been associated with bone loss in the mandible or maxilla, to include as due to GERD. Thus, service connection may not be established for compensation purposes for the Veteran's missing or damaged teeth. The Board is sympathetic to the Veteran's claim, and acknowledges the suffering she describes, caused by her dental problems. The Board has asked the RO to refer the Veteran's claim (in so far as it includes a request for VA treatment) to VHA for consideration, if such has not been done already. Further, the Board has recognized the overall effects of GERD-to specifically include its role in the deterioration of the Veteran's teeth-in assigning a higher rating for that disability above, based on symptoms productive of considerable impairment in health. Beyond this, the Board is prohibited by law from awarding service connection for compensation purposes, for the Veteran's dental problems, even on a secondary basis, without evidence of underlying bone disease or loss, or prior evidence of in-service trauma. Accordingly, the Board finds that entitlement to VA compensation benefits for a dental disorder is not warranted. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER 1. Entitlement to a 30 percent rating, but no higher, for service-connected GERD is granted. 2. Entitlement to an increased rating in excess of 50 percent for the service-connected anxiety disorder is denied. 3. The claim for entitlement to service connection for a left leg disability is reopened. 4. The claim for entitlement to service connection for a dental condition is reopened. 5. The claim for entitlement to service connection for headaches is reopened. 6. Entitlement to service connection for a left leg disability, other than varicose veins and radiculopathy, is denied. 7. Entitlement to service connection for a dental condition for compensation benefits is denied. REMAND Headaches Regarding the Veteran's claim for service connection for headaches, the Board notes that an addendum opinion was obtained regarding the nature of this disability in May 2016. The examiner opined that the headaches were less likely than not related to the Veteran's military service, based upon only one notation of headaches during military service. The examiner concluded that it was less likely than not that the present complaint of frequent and prostrating headaches are related to the single report of headaches during service. However, the examiner failed to provide a rationale in support of this conclusion, and did not explain the basis for determining why the in-service and present reports of headaches were unrelated. In light of these deficiencies, this matter must be remanded to obtain another addendum opinion regarding the etiology of the Veteran's headaches. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Increased Rating for Lumbar Spine Disability In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court determined that the final sentence of 38 C.F.R. § 4.59 requires VA examinations to include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. In evaluating the severity of the Veteran's back disability, the December 2012 and September 2015 VA examiners did not specify whether testing was completed in both active and passive motion, and in nonweight-bearing. In light of the Court's holding in Correia, coupled with the fact that VA has not assessed the severity of the disability in over two years, the Board finds that a remand is appropriate to afford the Veteran an updated and complete examination for her spine. Increased Rating for Varicose Veins The Board recognizes the July 2010 rating decision, in which the RO denied a rating in excess of 10 percent for the service-connected left leg varicose veins. Veteran submitted a VA Form 9 in March 2011, in which she indicated that the January 2011 Statement of the Case erroneously adjudicated a claim for service connection for a left leg disability, instead of an increase for varicose veins of the left leg. The Board will accept this statement from the March 2011 VA Form-9 as a notice of disagreement in response to the July 2010 rating decision. The next step in the appellate process is for the RO to issue to the Veteran and the Veteran's representative a Statement of the Case addressing this matter. See 38 C.F.R. § 19.29 (2017); Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). Consequently, this matter must be remanded to the RO for the issuance of a statement of the case. VA treatment records since June 2016 have been associated with the claims file. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify all VA and non-VA health care providers, other than those already associated with the claims file, and authorize VA to obtain non-VA records. Updated VA treatment records since June 2016 should also be obtained. 2. Obtain a medical opinion addressing the etiology of the Veteran's headaches. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. Following a review of the claims file, the reviewing examiner is requested to furnish an opinion with respect to the following question: Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's headaches had their onset in or are otherwise related to her period of active service? In rendering his or her opinion, the examiner should consider the documentation of a complaint related to headaches during service. A complete rationale should be given for the opinion expressed. In this regard, a discussion of the relevant facts and medical principles involved would be of considerable assistance to the Board. 3. The Veteran should be afforded a VA examination in order to determine the current severity of her service-connected lumbar spine disability. All pertinent evidence should be made available to and reviewed by the examiner. The examiner must make all findings relative to rating the Veteran's disabilities, to include joint testing for pain on both active and passive motion, and in weight-bearing and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. In addition to dictating objective test results, the examiner's report should fully describe the effects of the Veteran's disability on her occupational functioning and daily activities. With respect to flare-ups, the examiner should identify any functional loss caused by flare-ups, to include the amount of range of motion loss, if any, that is present during flare-ups. If the examination is not taking place during a flare-up, the examiner should elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups and estimate range of motion loss, in terms of degrees. Any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. The AOJ should ensure that the examiner provides all information required for rating purposes, to include an assessment as to whether the Veteran's back disability has manifested in incapacitating episodes required physician-prescribed bed rest, and if so, for what duration. 4. The Veteran and her representative must be provided a Statement of the Case addressing the Veteran's claim for an increased rating for the service-connected left leg varicose veins. If and only if, the Veteran files a timely substantive appeal should this issue be returned to the Board. See 38 C.F.R. § 19.29; Manlincon, 12 Vet. App. 238. 5. When the development requested has been completed, the case should be reviewed by AOJ on the basis of additional evidence. If the benefits sought are not granted, the Veteran and her representative should be furnished a Supplemental Statement of the Case (SSOC) and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ V. Chiappetta Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs