Citation Nr: 1804732 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 11-29 035 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a rating in excess of 20 percent for discogenic disc disease, lumbar spine (claimed as back condition with right leg pain, previously mechanical low back pain, DC 5292) as 20 percent disabling. 2. Entitlement to a compensable rating for right testicle mass. 3. Entitlement to a temporary total convalescence rating under 38 C.F.R. § 4.20 (2017). 4. Entitlement to a rating in excess of 10 percent for radiculopathy, right lower extremity associated with discogenic disc disease, lumbar spine (claimed as back condition with right leg pain, previously mechanical low back pain, DC 5292). 5. Entitlement to an evaluation in excess of 20 percent for radiculopathy, left lower extremity associated with discogenic disc disease, lumbar spine (claimed as back condition with right leg pain, previously mechanical low back pain, DC 5292). 6. Entitlement to a rating in excess of 30 percent for bilateral pes planus. 7. Entitlement to a rating in excess of 20 percent for residuals of right shoulder injury. 8. Entitlement to a rating in excess of 10 percent for tinnitus (also claimed as ear aches). 9. Entitlement to a rating in excess of 30 percent for unspecified depressive disorder (previously rated under 9434) associated with discogenic disc disease, lumbar spine (claimed as back condition with right leg pain, previously mechanical low back pain, DC 5292). 10. Entitlement to service connection for sleep apnea. 11. Entitlement to service connection for left shoulder strain. 12. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for right ankle disability (previously foot and ankle disability, DC 5299). 13. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for left ankle disability (previously foot and ankle disability, DC 5299). 14. Entitlement to service connection for carpal tunnel syndrome, left. 15. Entitlement to service connection for carpal tunnel syndrome, right. 16. Entitlement to service connection right knee condition (also claimed as knee and leg joints). 17. Entitlement to service connection for degenerative arthritis, left knee (also claimed as knee and leg joints). 18. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for headaches associated with bilateral hearing loss. 19. Entitlement to service connection for posttraumatic stress disorder (PTSD). 20. Entitlement to service connection for rash on thighs and testicles, to include as due to service-connected discogenic disc disease, lumbar spine. 21. Entitlement to service connection for a voiding disorder, to include as due to service-connected discogenic disc disease, lumbar spine. 22. Entitlement to service connection for bilateral hip/thigh joint condition. 23. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 24. Entitlement to special monthly compensation (SMC) based on aid and attendance/housebound. 25. Entitlement to automobile or other conveyance and adaptive equipment or adaptive equipment only. REPRESENTATION Veteran represented by: Douglas I. Friedman, Attorney at Law ATTORNEY FOR THE BOARD Steven D. Najarian, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1986 to August 1986, and from July 1990 to July 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of March 2009 by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, SC, and rating decisions of April 2013 and August 2015 rating decision by the Montgomery, Alabama RO. The Veteran requested a decision review officer (DRO) hearing. See February 2017 NOD. The Veteran has the right to request an RO hearing. See VA Adjudication Procedures Manual, M21, Part I, Chapter 4.1.l (updated Nov. 13, 2017). An RO hearing was scheduled to be held on April 13, 2017 at the Montgomery, Alabama RO. See March 2017 notification letter. By a filing of March 2017, the Veteran's attorney requested that the DRO call him in advance of the scheduled DRO hearing in order to "narrow the issues and save time for all concerned." Although VA's internal claims tracking system, the Veterans Appeals Control and Locator System (VACOLS), indicates that the scheduled DRO hearing was "canceled by the Veteran," there is no document of record indicating that the Veteran canceled the hearing. The Board will order that the DRO hearing requested by the Veteran be scheduled. The Veteran's claim for entitlement to an initial increased rating for residuals of a right shoulder injury was readjudicated by a September 2014 rating decision that increased the disability evaluation from 10 percent to 20 percent, with an effective date of September 22, 2014. As the increase did not constitute a full grant of the benefit sought, the Veteran's claim for a higher initial evaluation remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). Furthermore, the Veteran filed a notice of disagreement with respect to the effective date assigned for the increase. According to VACOLS, the RO has acknowledged the Veteran's February 2017 NOD with respect to the issue of entitlement to an earlier effective date for the grant of the rating increase. Therefore this situation is distinguishable from Manlincon (where an NOD had not been recognized), and a Manlincon remand is not warranted at this time as to the earlier effective date issue. See Manlincon v. West, 12 Vet. App. 238 (1999). The Veteran perfected an appeal concerning the issue of entitlement to service connection for erectile dysfunction. See NOD of June 2016; VA Form 9 of February 2017. By a rating decision of February 2017, the RO granted service connection for erectile dysfunction associated with unspecified depressive disorder. A noncompensable rating and an effective date of September 22, 2014 were assigned. The Veteran was also granted special monthly compensation from September 22, 2014 based on loss of use of a creative organ. Because the issue of service connection for erectile dysfunction has been resolved, the issue is no longer before the Board. See Grantham v. Brown, 114 F.3d 116 (Fed. Cir. 1997). According to VA's Veterans Appeals Control and Locator System, the RO has acknowledged the Veteran's August 2017 NOD with respect to the issue of entitlement to an earlier effective date for the grant of service connection for unspecified depressive disorder. Where a notice of disagreement has been filed but an statement of the case (SOC) has not been issued, the Board must remand the claim to the agency of original jurisdiction so that an SOC may be issued. See Manlincon v. West, 12 Vet. App. 238 (1999). Because the RO has acknowledged the NOD, however, this situation is distinguishable from Manlincon (where an NOD had not been recognized), and a Manlincon remand is not warranted at this time as to the earlier effective date issue. In June 2016, the Veteran filed a notice of disagreement as to the denial of a rating increase for service-connected tinnitus. The Veteran also checked the form box indicating disagreement as to the effective date of the award. Because the August 2015 rating decision with which the Veteran disagreed had denied a rating increase, there was no effective date with which the Veteran could disagree. Alternatively, if the Veteran seeks an earlier effective date than that already assigned for the award of service connection for tinnitus, that motion is legally precluded at this stage of his increased-rating claim. See 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2017). Final decisions may be reviewed through a claim of clear and unmistakable error or by the submission of new and material evidence. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). The Veteran has not alleged clear and unmistakable error. Furthermore, because the effective date upon receipt of new and material evidence after a final disallowance will be the date of receipt of the new claim or the date entitlement arose, whichever is later, it is not possible to reopen a claim for an earlier effective date based on the receipt of new and material evidence. See Leonard v. Principi, 405 F.3d 1333 (Fed. Cir. 2005). The same analysis applies with respect to the Veteran's filings that seek an earlier effective date for service-connected bilateral pes planus. The Veteran's June 2016 NOD noted disagreement as to the "effective date" of an August 2015 rating decision that denied a rating increase for pes planus. There was no effective date arising from the latter rating decision with which the Veteran could disagree. Furthermore, it is not possible to make a "freestanding" claim for an earlier effective date (other than on the basis of claim and unmistakable error) once a decision that establishes an effective date becomes final. See Rudd, supra. The issue of entitlement to service connection for ear aches has been raised by the record in a filing of VA Form 21-526b on May 25, 2015, but has not been adjudicated by the agency of original jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over the issue, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). The issues of relating to sleep disorder to include sleep apnea, left shoulder strain, rash on thighs and testicles, discogenic disc disease of the lumbar spine and associated radiculopathy of the bilateral lower extremities, bilateral pes planus, right shoulder injury, unspecified depressive disorder, right knee condition, degenerative arthritis of the left knee, bilateral hip/thigh joint condition, entitlement to a TDIU, entitlement to special monthly compensation based on aid and attendance/housebound, entitlement to automobile or other conveyance, and entitlement to adaptive equipment only are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's right testicle mass has not resulted in urinary or renal symptoms or any other significant symptoms during the period under review. 2. The Veteran did not undergo surgery pertaining to service-connected disability that resulted in incompletely healed surgical wounds, stumps of recent amputations, application of a body cast, use of a wheelchair or crutches, therapeutic immobilization, immobilization by cast, or the necessity of house confinement. 3. The 10-percent rating currently in effect for service-connected tinnitus is the maximum schedular rating 4. An unappealed May 2012 rating decision denied entitlement to service connection for right ankle disability. 5. Evidence received since the May 2012 rating decision that denied service connection for right ankle disability is cumulative in relation to the evidence of record at the time of the prior final denial and does not raise a reasonable possibility of substantiating the claim. 6. An unappealed May 2012 rating decision denied entitlement to service connection for left ankle disability. 7. Evidence received since the May 2012 rating decision that denied service connection for right ankle disability is cumulative in relation to the evidence of record at the time of the prior final denial and does not raise a reasonable possibility of substantiating the claim. 8. Carpal tunnel syndrome of the left hand is not shown at any time during the appeal period. 9. Carpal tunnel syndrome of the right hand is not shown at any time during the appeal period. 10. An unappealed November 1993 rating decision denied entitlement to service connection for headaches, residual of head injury. 11. Evidence received since the November 1993 rating decision that denied entitlement to service connection for headaches, residual of head injury is cumulative in relation to the evidence of record at the time of the prior final denial and does not raise a reasonable possibility of substantiating the claim. 12. At no time since the claim was filed has the Veteran been diagnosed with PTSD pursuant to the Diagnostic and Statistical Manual of Mental Disorders (DSM). 13. A voiding disorder was not manifest in service and is not attributable to service. CONCLUSIONS OF LAW 1. The criteria for a compensable evaluation for right testicle mass are not met or approximated. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. § 4.115a, 4.115b, Diagnostic Code 7529 (2017). 2. The criteria for a temporary total disability rating for a period of convalescence for treatment for service-connected disability have not been met or approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R §§ 3.102, 3.159, 4.30 (2017). 3. The claim for an initial rating greater than 10 percent for bilateral tinnitus is without legal merit. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.321(b), 4.1, 4.87, DC 6260 (2017). 4. The May 2012 rating decision denying service connection for right ankle disability is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2012). 5. As new and material evidence has not been received since the May 2012 rating decision, the claim of entitlement to service connection for right ankle disability is not reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 6. The May 2012 rating decision denying service connection for left ankle disability is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2012). 7. As new and material evidence has not been received since the May 2012 rating decision, the claim of entitlement to service connection for left ankle disability is not reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 8. Carpal tunnel syndrome of the left hand was not incurred in or aggravated by service or a service-connected disability. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2017). 9. Carpal tunnel syndrome of the right hand was not incurred in or aggravated by service or a service-connected disability. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2017). 10. The November 1993 rating decision denying service connection for headaches, residual of head injury is final. 38 U.S.C.§ 7105 (1991); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (1993). 11. As new and material evidence has not been received since the November 1993 rating decision that denied service connection for headaches, residual of head injury, the claim of entitlement to service connection for a headache disability is not reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 12. PTSD was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 13. A voiding disorder was not incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The VCAA applies to the instant claim. VA has satisfied the notification and duty-to-assist provisions of the VCAA. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate the claim. See 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c), (d) (2017). This duty to assist contemplates that VA will help a claimant obtain records relevant to the claim and that VA will provide a medical examination or obtain an opinion when necessary to decide the claim. See 38 C.F.R. § 3.159(c)(4) (2017). The evidence of record includes service treatment records, service personnel records, VA treatment records, private treatment records, and statements of the Veteran. The Veteran has identified no outstanding evidence pertaining to his disabilities that could be obtained to substantiate the claim, and the Board is unaware of any such outstanding evidence. The Veteran underwent VA examinations in March 2012, August 2015, and December 2016. The findings of the examination reports are adequate for adjudicatory purposes. See 38 C.F.R. § 3.159(c)(4) (2017); Barr v. Nicholson, 21 Vet. App. 303 (2007). VA is not required to provide a new medical examination for a claimant seeking to reopen a previously and finally disallowed claim unless new and material evidence had been presented. See 38 C.F.R. § 3.159(c)(4)(C)(iii) (2017); Woehlaert v. Nicholson, 21 Vet. App. 456, 463 (2007). Increased Rating Issues Rating Criteria, Generally Disability ratings assigned in accordance with VA's Schedule for Rating Disabilities are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321(a), 4.1 (2017). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2017). In determining the present level of a disability for any rating claim, the Board must consider the possible application of "staged" ratings for diverse symptoms meeting the criteria for different ratings in distinct time periods during the course of the appeal. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). A request for an increased rating must be viewed in light of the entire relevant medical history. See 38 C.F.R. § 4.1 (2012); Peyton v. Derwinski, 1 Vet. App. 282, 287 (1991). VA must consider all the evidence of record to determine when any ascertainable increase in severity of the rated disability may have occurred. See Hazan v. Gober, 10 Vet. App. 511 (1997); Swanson v. West, 12 Vet. App. 442 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. See 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Right Testicle Mass A rating decision of November 1993 granted service connection for right testicle mass. A noncompensable rating and an effective date of July 9, 1993 were assigned. The Veteran did not appeal. In October 2008, the Veteran filed a claim for rating increase, which was denied by a rating decision of March 2009. The Veteran appealed. See NOD of March 2010; VA Form 9 of October 2011. Under Diagnostic Code 7529, which relates to benign neoplasms of the genitourinary system, the disability should be rated as voiding dysfunction or renal dysfunction, whichever is predominant. Voiding dysfunction is rated under the three subcategories of urine leakage, urinary frequency, or obstructed voiding. See 38 C.F.R. § 4.115 (2017). The Veteran has not had renal dysfunction at any time during the period under review. The Veteran reports incontinence, and VA treatment records list "incontinence, urge" as an active problem. See VA treatment records of July 2013, June 2015, and August 2015. A November 2008 VA genitourinary examination made a finding of stress incontinence. It is not apparent upon what basis the findings of incontinence were made other than via the Veteran's self-reported medical history. The probative value of this evidence is outweighed by other evidence of record. The Veteran underwent a VA examination in December 2016. The examiner noted a 2008 diagnosis of spermatocele for which the Veteran did not take continuous medication. The examiner made a finding of no renal dysfunction and no voiding dysfunction. The right testicle was found to be abnormal. There was a small cyst head of the right epididymis, which was smooth, firm, and tender to palpation. The diagnosis based on ultrasound evaluation was spermatocele right epididymis. No competent evidence of record associates voiding dysfunction of the Veteran with his right testicle mass. The December 2016 examiner diagnosed spermatocele of the right epididymis and specifically found that the Veteran had no voiding dysfunction. The Veteran, as a layperson, is competent to report his experienced symptoms of urinary frequency and incontinence. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran is not competent to associate his voiding symptoms with his right testicle mass. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428 (2011). Because no competent evidence of record indicates that the Veteran's urinary symptoms are related to his right testicle mass, the Veteran is not entitled to a compensable rating for his service-connected right testicle mass based on voiding dysfunction at any time during the period under review. See Hart v. Nicholson, 21 Vet. App. 505, 509 (2007). Temporary Total Convalescence Rating A total disability rating (100 percent) will be assigned without regard to other provisions of the Rating Schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted, effective from the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release. Entitlement requires that the service-connected disability resulted in (1) surgery necessitating at least one month of convalescence; (2) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. See 38 C.F.R. § 4.30 (2017). The Veteran has not specified a disability or time period that resulted in the required convalescence following surgery, surgery with residuals or house confinement, or joint immobilization by cast. See Veteran's statement of October 2008. An August 2015 VA examination report for the back indicates that the Veteran has undergone no back surgery. The Veteran denies any surgery relating to the knees, and none is noted. See August 2015 VA examination report for the knees. There also has been no surgery of the feet or male reproductive system. See March 2012 VA examination report for pes planus; December 2016 VA examination report for male reproductive system conditions. On a VA medical questionnaire of August 2013, the Veteran denied having had any surgery. It is not apparent upon what basis this claim was raised. There is no factual basis upon which it rests. No argument was advanced by the Veteran's representative. A question is raised as to why it was even included. After reviewing the totality of the record, the Board finds the preponderance of the evidence to be against an award of a temporary total rating under 38 C.F.R. § 4.30. The preponderance of the evidence is against finding that the Veteran underwent surgery or that he required immobilization by cast, without surgery, of one major joint or more. Tinnitus (Also Claimed as Ear Aches) A rating decision of November 1993 granted service connected for tinnitus. A 10 percent rating and an effective date of July 9, 1993 were assigned. The Veteran did not appeal. In May 2015, the Veteran filed a claim for rating increase, which was denied by a rating decision of August 2015. The Veteran appealed. See NOD of June 2016; VA Form 9 of February 2017. A VA examination of August 2015 noted the Veteran's constant tinnitus. A single 10 percent evaluation is assigned for recurrent tinnitus pursuant to Disability Code (DC) 6260, whether the sound is perceived as being in one ear, both ears, or in the head. See 38 C.F.R. § 4.87, DC 6260, Note 2 (2017). Because DC 6260 precludes separate, 10-percent schedular ratings for bilateral tinnitus, the Veteran's claim for an evaluation greater than 10 percent must be denied. See Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The Board notes the Veteran's service-connection claim for severe, chronic ear aches as due to service-connected bilateral hearing loss and bilateral tinnitus. See VA Form 21-526b in May 2015. A rating decision of August 2015 denied a rating increase for tinnitus (also claimed as ear aches) and noted that, according to the VA examiner, the Veteran's ear aches include almost constant tinnitus. To date, no rating decision has been issued with respect to the claim of service connection for ear aches as caused or aggravated by service-connected tinnitus. The claim is separate from the Veteran's claim for an increased rating for service-connected tinnitus. Accordingly, the Board will refer the former issue to the AOJ. See 38 C.F.R. § 19.9(b) (2017). Service Connection Issues New and Material Evidence, Generally Generally, a claim that has been denied in a final, unappealed rating decision may not thereafter be reopened and allowed. See 38 U.S.C. § 7105(c) (2012). An exception provides that VA shall reopen a disallowed claim if new and material evidence is presented or secured with respect to the claim. See 38 U.S.C. § 5108 (2012). New and material evidence is defined as evidence not previously submitted to agency decision makers which bears directly and substantially upon the specific matter under consideration. Such new and material evidence can be neither cumulative nor redundant of the evidence previously of record and must raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156(a) (2017). Evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence was not previously presented to the Board. See Anglin v. West, 203 F.3d 1343 (2000). The Board will generally presume the credibility of the evidence in determining whether evidence is new and material. See Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The threshold for determining whether new and material evidence has been submitted is low. See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Criteria of Service Connection Service connection will be granted for a current disability that resulted from an injury or disease incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). Generally, service connection requires: (1) a present disability; (2) an 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. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2017). Service connection may be granted on a secondary basis for disability which is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a) (2017). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service-connected. See 38 C.F.R. § 3.310(b) (2017). In the case of any veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. See 38 U.S.C. § 1154(b) (2012); 38 C.F.R. § 3.304(d) (2017). For a veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for certain chronic diseases, including arthritis, psychoses, and organic diseases of the nervous system, if the chronic disease is shown as such during service or within one year of discharge from service. See 38 U.S.C. §§ 1101, 1112, 1113 (2012); 38 C.F.R. §§ 3.303(b), 3.307, 3.309 (2017). When the fact of chronicity in service is not adequately supported, a continuity of symptomatology since service is an alternative means of establishing service connection. See 38 C.F.R. § 3.303(b) (2017); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The claimant bears the evidentiary burden of establishing all elements of a service connection claim, including the nexus requirement. See 38 U.S.C.A. § 5107(a) (2012); Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. See 38 U.S.C. § 1154(a) (2012). The Board must give a claimant the benefit of the doubt as to any issue material to the determination of a matter when there is an approximate balance of positive and negative evidence. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). For a claim to be denied on the merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Bilateral Ankle Disability In July 1993, the Veteran filed a service-connection claim for bilateral feet and ankle pain. A rating decision of November 1993 denied service connection for "foot and ankle disability (not found on last examination)." The Veteran did not appeal. In October 2011, the Veteran filed a service-connection claim for "bilateral foot condition (multiple lumps)." A rating decision of May 2012 denied service connection for left foot disability (previously foot and ankle disability, DC 5299) and right foot disability (previously foot and ankle disability, DC 5299). See notification letter of May 2012. The Veteran did not perfect an appeal as to the May 2012 rating decision. A VA Form 9 filed in August 2014 is determined to be untimely, having been filed more than 60 days following the issuance of the February 2014 SOC. In September 2014, the Veteran filed a service connection claim for disabilities of the left ankle and right ankle. The Board must address the issue of whether new and material evidence has been received. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). In so doing, the Board looks to the evidence submitted since the last final denial of the claim on any basis. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). The evidence of record at the time of the May 2012 rating decision consisted of service treatment records, statements of the Veteran, a March 2012 VA examination report for the feet, and VA treatment records. The May 2012 rating decision determined that the lack of an in-service injury or disease was an evidentiary defect. Following the May 2012 rating decision, records of postal employment, service personnel records, VA treatment records, treatment records furnished by the Social Security Administration (SSA), an August 2015 VA examination report for foot conditions, statements of the Veteran, lay statements, and a private vocational opinion have been added to the record. The Veteran argues that service connection for left and right ankle disability should be granted as secondary to his service-connected bilateral pes planus or to his "back and legs." See VA Form 9 of August 2014 (untimely); VA Form 9 of February 2017; NOD of June 2016. The Veteran is service-connected for a low back disability and associated radiculopathy of the left and right lower extremities. A new etiological theory of entitlement does not constitute a new claim. See Ashford v. Brown, 10 Vet. App. 120, 123 (1997). New and material evidence must be submitted following the prior final denial of service connection in May 2012, despite the change in theory from direct to secondary service connection. Other than the Veteran's statements as to possible secondary service connection, the newly submitted evidence either does not relate to the ankles or, if relating to the ankles, is immaterial to an in-service occurrence or a nexus to service. After a thorough review of the record, the Board concludes that the Veteran has not submitted new and material evidence concerning the unestablished facts of an in-service injury or a relationship between a current disability and service. The evidence received since the May 2012 rating decision that denied service connection for a bilateral ankle disability is not probative of any missing element of service connection. Evidence merely cumulative of other evidence of record cannot be new and material even if it was not been previously presented to VA. See Anglin v. West, 203 F.3d 1343 (2000). Because new and material evidence has not been received, the Veteran's claim of entitlement of service connection for disability of the left ankle and right ankle may not be reopened. Bilateral Carpal Tunnel Syndrome The Veteran seeks service connection for carpal tunnel syndrome on a secondary basis as "resulting from service connected disabilities." See NOD of June 2016. He has argued specifically that he has carpal tunnel syndrome as secondary to his disabilities of the back and feet. He maintains that carpal tunnel syndrome is caused by the undue pressure resulting from his need to grasp a walker to stand and walk. See Veteran's claim of September 2014; VA Form 9 of February 2017. The Veteran is service connected for a low back disability and associated radiculopathy of the bilateral lower extremities, bilateral pes planus, unspecified depressive disorder, right shoulder injury, tinnitus, bilateral hearing loss, right testicle mass, and erectile dysfunction. The Veteran has not been diagnosed with carpal tunnel syndrome, and no hand or wrist symptoms are noted in the VA treatment records. As a layperson, the Veteran is competent to report his experienced symptoms of the hands. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran is not competent to diagnose a hand disability or carpal tunnel syndrome. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Furthermore, no Jandreau exception applies here, as the Veteran is not competent to identify the medical condition, is not reporting a contemporaneous medical diagnosis, and is not describing symptoms at the time that support a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). There is no competent evidence of record that the Veteran has carpal tunnel syndrome or that any current hand disability is related to service or a service-connected disability. With a preponderance of the evidence being against finding a current disability of the left hand or right hand, to include carpal tunnel syndrome, the claim must be denied. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997). Headaches In July 1993, the Veteran filed a service-connection claim for head injury with headaches. A rating decision of November 1993 denied service connection for headaches as a residual of head injury. The Veteran did not appeal the rating decision, which became final. In May 2015, the Veteran filed a service-connection claim for headaches as "secondary to service-connected disabilities [of] ears (loss of hearing and ringing of the ears)." The Veteran is service connected for tinnitus and bilateral hearing loss. The Board must address the issue of whether new and material evidence has been received. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). In so doing, the Board looks to the evidence submitted since the last final denial of the claim on any basis. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). The evidence of record at the time of the November 1993 rating decision consisted of service treatment records, a VA medical examination report of September 1993, and statements of the Veteran. The VA examination report noted an impression of history of recurrent headaches, status post head injury. The November 1993 rating decision determined that the service treatment records showed no treatment for a head injury and that the separation examination report indicated headaches after a head trauma in Korea in 1992. There were no other findings. Following the November 1993 rating decision, the following evidence has been added to the record: records of postal employment, service personnel records, VA treatment records, SSA treatment records, VA examination reports, statements of the Veteran, lay statements, and a private vocational opinion. The Veteran argues that service connection for headaches should be granted as secondary to his service-connected disabilities of the low back, tinnitus, and bilateral hearing loss. See claim of May 2015; NOD of June 2016; VA Form 9 of February 2017. A new etiological theory of entitlement does not constitute a new claim. See Ashford v. Brown, 10 Vet. App. 120, 123 (1997). New and material evidence must be submitted following the prior final denial of service connection, despite the change in theory from direct to secondary service connection. The Veteran underwent a VA examination for headaches in August 2015. The examiner offered a negative nexus opinion, finding that the condition claimed is less likely than not proximately due to, or the result of, the Veteran's service connected condition. The examiner's rationale was that the Veteran has no current diagnosis of headaches, that the current clinical exam was "essentially negative," and that headaches are not a well-documented secondary condition related to hearing loss and/or tinnitus. Evidence that does not support a claim for service connection is not considered to be new and material evidence. See Woehlart v. Nicholson, 21 Vet.App. 456, 462 (2007). The Board notes that the August 2015 examination is arguably inadequate because the examiner's rationale (that the Veteran had not been diagnosed with headaches and that the examination was "essentially negative") is contradicted by the examiner's finding of characteristic prostrating attacks of migraine pain once per month. See Nieves-Rodriguez v. Peake, 22 Vet.App. 295, 304 (2008). The Board must consider all evidence of record, including any new VA examinations obtained by the RO, when determining whether a claim should be reopened, but the duty to ensure that an adequate examination was provided, as set forth in Barr v. Nicholson, 21 Vet. App. 303 (2007), is not applicable unless a claim is reopened for consideration on the merits. Once the Board decides that a claim is not be reopened, the conditional duty to provide a new VA examination is extinguished. See Woehlaert, supra, at 464. Because the Board determines that the Veteran has not submitted new and material evidence, the adequacy of the above examination is moot, and there is no need to afford the Veteran a new VA examination. Other than the Veteran's statements as to secondary service connection, the newly submitted evidence does not relate to headaches, or, if relating to headaches, is immaterial to a nexus to service or a service-connected disability. After a thorough review of the record, the Board concludes that the Veteran has not submitted new and material evidence concerning the unestablished fact of a relationship between current disability and service. Evidence merely cumulative of other evidence of record cannot be new and material even if it was not previously presented to VA. See Anglin v. West, 203 F.3d 1343 (2000). Additional VA medical evidence notes the Veteran's headache symptoms, but the fact of current, recurrent headaches was of record at the time of the November 1993 rating decision, and the November 1993 rating decision did not deny service connection on the basis of a lack of a current disability. Evidence received since the November 1993 rating decision that denied service connection for headaches as a residual head injury is not probative of any missing element of service connection. The Veteran, as a layperson, is not competent to associate his current headaches symptoms with service or a service-connected disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). It is the claimant's responsibility to present and support a claim for benefits. See 38 U.S.C. § 5107(a) (2012). The Veteran has been accorded the opportunity to submit new and material evidence and has failed to do so. Because new and material evidence has not been received, the Veteran's claim of entitlement of service connection for a headache disability may not be reopened. Acquired Psychiatric Disability Consistent with Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Veteran's claim of service connection for PTSD with major depression has been construed broadly to include any acquired psychiatric disability. A claim for a mental health disability includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and other information of record. The Veteran has been granted service connection for unspecified depressive disorder. See rating decision of February 2017. Establishing service connection for PTSD generally requires: (1) medical evidence diagnosing PTSD in conformance with established criteria; (2) a link, established by medical evidence, between a veteran's present symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. See 38 C.F.R. §§ 3.304(f), 4.125 (2017) (requiring PTSD diagnoses to conform to the criteria in the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5)); Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010); Cohen v. Brown, 10 Vet. App. 128, 139 (1997). A veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor in the absence of clear and convincing evidence to the contrary, if the veteran engaged in combat with the enemy, the claimed stressor is related to that combat, and the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service. See 38 C.F.R. § 3.304(f)(2) (2017). In October 2008, the Veteran filed a service-connection claim for depression, to include as secondary to back disability and to loss of work. A March 2009 rating decision denied service connection for depression. The Veteran perfected an appeal. See notice of disagreement of March 2010; VA Form 9 of October 2011. In September 2014, the Veteran filed a service-connection claim for PTSD and depression. A rating decision of August 2015 denied service connection for PTSD. The Veteran perfected an appeal as to the PTSD issue. See VA Form 9 of February 2017. As noted above, a service-connection claim for depression was already on appeal. See VA Form 9 of October 2011. A rating decision of February 2017 granted service connection for unspecified depressive disorder with a 30 percent rating and an effective date of October 27, 2008. Accordingly, the issue of service connection for depression has been resolved and is no longer before the Board. See Grantham v. Brown, 114 F.3d 116 (Fed. Cir. 1997). The Veteran filed a notice of disagreement as to both the rating and effective date assigned. See NOD of August 2017. There is no competent PTSD diagnosis of record. The Veteran has been diagnosed with unspecified depressive disorder. See VA examination report. He also has been diagnosed with adjustment disorder with depressed mood. See January 2013 VA treatment record. The Veteran alleges that he suffers from anxiety and depression due to the stress of his service-connected disabilities. See VA Form 9 of February 2017. Marriage difficulties during service, as well as witnessing a soldier being trapped under a trailer during service, are also cited as stressful events that cause his psychological symptoms, including depression. See VA Form 21-0781a of September 2014. VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability or death benefits. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (construing, in relevant part, 38 U.S.C. § 1154(a)). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) 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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The Veteran, as a layperson, is competent to report the symptoms that he has experienced, but service connection for PTSD specifically requires, in part, medical evidence establishing a diagnosis of the disability. See 38 C.F.R. § 3.304(f) (2017). The Veteran is not competent to associate any of his claimed symptoms to a diagnosis of PTSD. Such opinion requires specific medical training. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See 38 C.F.R. § 3.159(a)(1) (2017). Accordingly, the statements offered by the Veteran in support of his own claim do not establish PTSD. The Veteran's claim of service connection for PTSD fails on the basis of a lack of medical evidence diagnosing PTSD in conformity with criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. A preponderance of the competent evidence is against finding a diagnosis of PTSD made in accordance with 38 C.F.R. § 4.125 at any time since the Veteran's claim was filed. Therefore service connection cannot be granted. See Degmetich v. Brown, 104 F.3d 132 (Fed. Cir. 1997); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998). Voiding Disorder The Veteran seeks service connection for a voiding disorder allegedly caused by his service-connected discogenic disc disease of the lumbar spine. See Veteran's claim of September 2014. He further alleges that "medication for service-connected conditions" causes him to leak urine. See VA Form 9 of February 2017. He has also argued without specification that the disability is due to "service-connected disability." See NOD of June 2016. The Veteran reports incontinence, and VA treatment records list "incontinence, urge" as an active problem. See VA treatment records of July 2013, June 2015, and August 2015. A November 2008 VA genitourinary examination made a finding of stress incontinence and diagnosed hydrocele with the associated problem of right testicle mass. A December 2016 VA examination for male reproductive system conditions determined that the Veteran does not have a voiding dysfunction. An August 2015 VA examination of the back made no finding of a voiding disorder in the report section relating to any other associated symptoms. The Veteran's service treatment records note no voiding or urinary symptoms. The exit examination report of June 1993 noted "mass right testicle" in relation to the genitourinary system and made no finding as to voiding. The Veteran replied negatively as to frequent or painful urination and reported no urinary symptoms. The Veteran is competent to report his experienced symptoms of urinary frequency and incontinence. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran, as a layperson, is not competent to associate his voiding symptoms with service or a service-connected disability, including medication taken for such disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Accordingly, the Veteran's opinion as to the etiology of his incontinence is without probative value. The Board finds that the preponderance of the evidence is against the claim. Without competent and credible evidence of an association between the Veteran's disorder and his active duty service or a service-connected disability, to include his low back disability and right testicle mass, service connection is not warranted. The benefit-of-the-doubt doctrine does not apply as the preponderance of the evidence is against the claim. See 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to a compensable rating for right testicle mass is denied. Entitlement to a temporary total convalescence rating under 38 C.F.R. § 4.30 is denied. New and material evidence has not been received to reopen the claim of entitlement to service connection for a right ankle disability. The benefit sought on appeal remains denied. New and material evidence has not been received to reopen the claim of entitlement to service connection for a left ankle disability. The benefit sought on appeal remains denied. Entitlement to service connection for carpal tunnel syndrome, left, is denied. Entitlement to service connection for carpal tunnel syndrome, right, is denied. New and material evidence has not been received to reopen the claim of entitlement to service connection for headaches. The benefit sought on appeal remains denied. Entitlement to service connection for headaches associated with bilateral hearing loss is denied. Entitlement to service connection for posttraumatic stress disorder is denied. Entitlement to service connection for a voiding disorder is denied. REMAND Increased Rating Issues Low Back Disability and Associated Radiculopathy of the Bilateral Lower Extremities A rating decision of November 1993 granted service connection for mechanical low back pain and assigned a 20 percent rating and an effective date of July 9, 1993. The Veteran did not appeal. In October 2008, the Veteran filed a claim for an increased rating. A rating decision of March 2009 continued the rating of 20 percent rating for the disability, which was re-designated as discogenic disc disease, lumbar spine (claimed as back condition with right leg pain, previously mechanical low back pain, DC 5292). The Veteran appealed. See NOD of March 2010; VA Form 9 of October 2011. In September 2014, the Veteran filed a claim for rating increase with respect to discogenic disc disease of the lumbar spine. As noted above, the Veteran already had a pending appeal as to that issue dating from the rating decision of March 2009. The RO issued a statement of the case (SOC) in February 2017 that continued the 20 percent rating for discogenic disc disease of the lumbar spine. The SOC also determined that service connection was warranted for radiculopathy of the left and right lower extremities associated with discogenic disc disease of the lumbar spine. The Veteran underwent a VA examination for the back in August 2015. The examiner noted the Veteran's report of back flare-up characterized by a worsening of symptoms with lying down, sitting awkwardly, or prolonged standing or walking. The examiner did not offer an opinion with respect to whether pain, weakness, fatigability, or incoordination significantly limit functional ability with flare-ups or repeated use over a period of time. The rationale was that doing so would be resorting to mere speculation, as opinions regarding functional limitations during flare-ups or repeated use over a period of time rely on subjective data. In Sharp v. Shulkin, No. 16-1385, decided September 6, 2017, the United States Court of Appeals for Veterans Claims clarified the responsibilities of a VA examiner and the Board when an examiner is asked to provide an opinion as to additional functional loss during flare-ups of musculoskeletal disability pursuant to DeLuca v. Brown, 8 Vet. App. 202 (1995). Case law and VA guidelines anticipate that examiners will offer flare-up opinions based on estimates derived from information procured from relevant sources, including lay (non-expert) statements. An examiner must do all that reasonably should be done to become informed before concluding that a requested opinion cannot be provided without resorting to speculation. Sharp found a VA examination to be inadequate because the examiner, although acknowledging that the appellant was not then suffering from a flare of any of his conditions, failed to ascertain adequate information, such as frequency, duration, characteristics, severity, and functional loss, regarding the flare-ups by alternative means. The Veteran claim of entitlement to an increase rating for his discogenic disc disease of the lumbar spine must be remanded to obtain a new medical examination that appropriately addresses the Veteran's flare ups according to the guidelines of Sharp. The related issues of entitlement to increased ratings for radiculopathy of the bilateral lower extremities (associated with back disability) is intertwined with the back issue inasmuch as Note (1) of the General Rating Formula for Diseases and Injuries of the Spine (38 C.F.R. 4.71a) instructs VA to evaluate any associated objective neurologic abnormalities when evaluating a back/spinal disability. To the extent that the Veteran's bilateral lower extremity radiculopathy is essentially a manifestation of a neurological pathology sited in the spine, additional development of the evidence concerning the severity of the Veteran's back disability may reasonably pertain to the radiculopathy issue as well. The Board notes that VA's disability benefits questionnaires and examination reports addressing back disabilities frequently detail intertwined lower extremity radiculopathy manifestations. Bilateral Pes Planus A rating decision of May 2012 granted service connection for bilateral pes planus. An evaluation of 30 percent and an effective date of October 17, 2011 were assigned. The Veteran filed an NOD in June 2016 but did not perfect an appeal. A VA Form 9 filed by the Veteran in August 2014 was determined by the RO to be untimely because filed more than 60 days after the issuance of an SOC in February 2014. In September 2014, the Veteran filed a claim for rating increase, which was denied by a rating decision of August 2015. The Veteran appealed. See NOD of June 2016; VA Form 9 of February 2017. The Veteran underwent a VA examination in August 2015. The examiner noted the Veteran's report of flare-ups that impact that function of the foot and that are worse with prolonged standing or walking. The examiner found no functional loss during flare-ups or when the feet are used repeatedly over a period of time. The examiner determined that an opinion regarding functional limitations during flare-ups or repeated use over a period of time was not feasible, as the examiner would be relying on subjective data and therefore resorting to mere speculation in rendering the opinion. In Sharp v. Shulkin, No. 16-1385, decided September 6, 2017, the United States Court of Appeals for Veterans Claims (the Court) clarified the responsibilities of a VA examiner and the Board when an examiner is asked to provide an opinion as to additional functional loss during flare-ups of musculoskeletal disability pursuant to DeLuca v. Brown, 8 Vet. App. 202 (1995). Case law and VA guidelines anticipate that examiners will offer flare-up opinions based on estimates derived from information procured from relevant sources, including lay (non-expert) statements. An examiner must do all that reasonably should be done to become informed before concluding that a requested opinion cannot be provided without resorting to speculation. Sharp found a VA examination to be inadequate because the examiner, although acknowledging that the appellant was not then suffering from a flare of any of his conditions, failed to ascertain adequate information, such as frequency, duration, characteristics, severity, and functional loss, regarding the flare-ups by alternative means. The Veteran's claim of entitlement to an increased rating for bilateral pes planus must be remanded to obtain a new medical examination that appropriately addresses the Veteran's flare ups according to the guidelines of Sharp. Furthermore, clarification is needed as to certain findings in the August 2015 examination report. It was noted, on the one hand, that the Veteran reported flare-ups that impact the functioning of the foot. On the other hand, the examiner noted that the Veteran made no report of functional loss or functional impairment of the foot. It is the factually accurate, fully articulated, sound reasoning for the conclusion that gives probative value to a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet.App. 295, 304 (2008). If an examination report does not contain sufficient detail, it is incumbent upon the Board to return the report as inadequate for evaluation purposes. See 38 C.F.R. § 4.2 (2016); Bowling v. Principi, 15 Vet.App. 1, 12 (2001). Right Shoulder A rating decision of November 1993 granted service connection for residuals of a right shoulder injury. A 10 percent rating and an effective date of July 9, 1993 were assigned. The Veteran did not appeal. In September 2014, the Veteran filed a claim for rating increase, which was denied by a rating decision of August 2015. The Veteran appealed. See NOD of June 2016; VA Form 9 of February 2017. In August 2015, the Veteran underwent a VA examination for shoulder and arm conditions. The examiner noted the Veteran's report of flare-ups with lifting. The examination was not conducted during a flare-up, and the examiner was unable to state an opinion, without report to mere speculation, as to whether pain, weakness, fatigability, or incoordination significantly limit functional ability with flare-ups. The explanation was that opinions regarding functional limitations during flare-ups or repeated use over a period of time are not feasible as this relies on subjective data. In Sharp v. Shulkin, No. 16-1385, decided September 6, 2017, the United States Court of Appeals for Veterans Claims (the Court) clarified the responsibilities of a VA examiner and the Board when an examiner is asked to provide an opinion as to additional functional loss during flare-ups of musculoskeletal disability pursuant to DeLuca v. Brown, 8 Vet. App. 202 (1995). Case law and VA guidelines anticipate that examiners will offer flare-up opinions based on estimates derived from information procured from relevant sources, including lay (non-expert) statements. An examiner must do all that reasonably should be done to become informed before concluding that a requested opinion cannot be provided without resorting to speculation. Sharp found a VA examination to be inadequate because the examiner, although acknowledging that the appellant was not then suffering from a flare of any of his conditions, failed to ascertain adequate information, such as frequency, duration, characteristics, severity, and functional loss, regarding the flare-ups by alternative means. The Veteran's claim of entitlement to an increased rating for right shoulder injury must be remanded to obtain a new medical examination that appropriately addresses the Veteran's flare ups according to the guidelines of Sharp. Unspecified Depressive Disorder By a rating decision of February 2017, the RO granted service connection for unspecified depressive disorder (previously rated under 9434) associated with discogenic disc disease, lumbar spine (claimed as back condition with right leg pain, previously mechanical low back pain, DC 5292). A 30-percent rating and an effective date of October 27, 2009 were assigned. In August 2017, the Veteran filed a notice of disagreement as to both the evaluation and the effective date of the award. A statement of the case pertaining to the issue of an increased rating for the grant of service connection for unspecified depressive disorder has yet to be issued by the RO. Where a notice of disagreement has been filed but an SOC has not been issued, the Board must remand the claim to the agency of original jurisdiction so that an SOC may be issued. See Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the Board will remand this issue. According to VACOLS, the RO has acknowledged the Veteran's August 2017 NOD with respect to the issue of entitlement to an earlier effective date for the grant of service connection. Therefore, with respect to that issue, the situation is distinguishable from Manlincon (where an NOD had not been recognized), and a Manlincon remand is not warranted at this time as to the earlier effective date issue. TDIU A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more service-connected disabilities, provided that one of those disabilities is ratable 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2017). Pursuant to 38 C.F.R. § 4.16(b), when a claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), the case shall be submitted for extraschedular consideration in accordance with 38 C.F.R. § 3.321. Two or more issues are inextricably intertwined if one claim could have significant impact on the other. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Here the Veteran's claim of entitlement to a TDIU is inextricably intertwined with the remanded claims. Development of the Veteran's remanded claims may impact his claim for a TDIU. Accordingly, the Board will remand the TDIU claim. Special Monthly Compensation, Automobile or Other Conveyance and Adaptive Equipment, and Adaptive Equipment Only The Veteran claims entitlement to special monthly compensation based on the need for aid and attendance or on account of being housebound. He also seeks entitlement to automobile and adaptive equipment or for adaptive equipment. See Veteran's claim of September 2014. The special monthly compensation provided for by 38 U.S.C. § 1114(s) is payable where a veteran has a single service-connected disability rated as total and, (1) has additional service-connected disability or disabilities independently ratable at 60 percent, or (2) is permanently housebound by reason of service-connected disability or disabilities. SMC under 38 U.S.C.§ 1114(l) is payable for anatomical loss or loss of use of both feet, one hand and one foot, blindness in both eyes with visual acuity of 5/200 or less, or being permanently bedridden or so helpless as to be in need of regular aid and attendance. See 38 U.S.C. § 1114(l) (2012); 38 C.F.R. § 3.350(b) (2017). In order to obtain financial assistance in purchasing an automobile and/or adaptive equipment, a veteran must be entitled to compensation for any of the following disabilities: (i) the loss or permanent loss of use of one or both feet; (ii) the loss or permanent loss of use of one or both hands; (iii) the permanent impairment of vision of both eyes; (iv) a severe burn injury; or, (v) amyotrophic lateral sclerosis. See 38 U.S.C. § 3902 (2012); 38 C.F.R. § 3.808 (b)(1) (2017). A veteran who is not eligible for assistance under the foregoing criteria may nevertheless be entitled to adaptive equipment if he or she is entitled to VA compensation for ankylosis of one or both knees, or of one or both hips. See 38 U.S.C. § 3902 (b)(2) (2012); 38 C.F.R. § 3.808 (b)(1)(iv) (2017). The issues of entitlement to SMC, automobile or other conveyance and adaptive equipment, and adaptive equipment only are remanded as inextricably intertwined with the remanded claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Service Connection Issues Sleep Apnea In July 2012, the Veteran filed a service connection claim for sleep apnea, which was denied by a rating decision of April 2013. The Veteran's filed a notice of disagreement in April 2013. Although the Veteran used the word "reconsideration" in the latter filing, he clearly expressed disagreement with the rating decision's finding that sleep apnea did not have its onset during service and further argued in favor of recurrent symptoms since service. The RO construed the Veteran's April 2013 filing as a motion for reconsideration and denied it on the basis that no new and material evidence had been submitted. See rating decision of April 2014. On April 13, 2015, the Veteran filed a notice of disagreement with respect to the April 2014 rating decision, which had been mailed to him on April 10, 2014. Although it was untimely under 38 U.S.C. § 7105(b)(1), the April 2015 NOD was recognized the RO. An SOC and a supplemental statement of the case (SSOC) were issued in April 2016 and February 2017, respectively. The April 2016 SOC refused to "reopen" the denial of service connection on the basis that no new and material evidence had been submitted following the April 2014 rating decision. The SSOC of February 2017 listed entitlement to service connection for sleep apnea as an issue but did not analyze it on the basis that no additional evidence pertaining to the disability had been submitted. Having filed a timely an NOD in April 2013, the Veteran is entitled to a statement of the case as to the merits of the service connection issue. See 38 C.F.R. § 19.29 (2017). Therefore the appropriate Board action is to remand the issue for the issuance of a statement of the case. See Manlincon v. West, 12 Vet. App. 238 (1999). Left Shoulder In September 2014, the Veteran filed a service-connection claim for left shoulder strain, which was denied by an August 2015 rating decision. The Veteran appealed. See NOD of June 2016; VA Form 9 of February 2017. Checked boxes on the June 2016 NOD form indicated disagreement as to the denial of service connection, effective date of the award, and evaluation of the disability. Because service connection had been denied, the latter two issues did not exist. An SOC of January 2017 and an SSOC of February 2017 continued the denial of service connection. In February 2017, the Veteran requested a hearing at the RO before a decision review officer (DRO). The Veteran has the right to request an RO hearing. See VA Adjudication Procedures Manual, M21, Part I, Chapter 4.1.l (updated Nov. 13, 2017). An RO hearing was scheduled to be held on April 13, 2017 at the Montgomery, Alabama RO. See March 2017 notification letter. By a filing of March 2017, the Veteran's attorney requested that the DRO call him in advance of the scheduled DRO in order to "narrow the issues and save time for all concerned." Although VACOLS indicates that the scheduled DRO was "canceled by the Veteran," there is no document of record indicating that the Veteran canceled the hearing. The Board will remand for the scheduling of the DRO hearing requested by the Veteran. Bilateral Knee Disability The Veteran has arthritis in both knees. See August 2015 VA examination report. The Veteran alleges that his disability of the knees is caused by his service-connected disabilities of the low back, bilateral pes planus, and radiculopathy of the bilateral lower extremities ("legs"), which, he maintains, cause him to walk unnaturally. The August 2015 VA examiner determined that the Veteran's left knee disability is less likely than not due to, or the result of, service-connected disability, including the low back disability and bilateral pes planus. The rationale was the arthritis of the left knee was more likely caused by direct overuse. The August 2015 examiner offered no nexus opinion with respect to whether service-connected disability aggravates the Veteran's left knee disability or whether arthritis of the right knee is caused or aggravated by service or a service-connected disability. The Board will remand for a new VA medical examination and full and adequate nexus opinions. See 38 U.S.C. § 5103A(d) (2012); 38 C.F.R. §§ 3.159(c)(4), 19.9(a) (2017); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Rash on Thighs and Testicles The Veteran seeks service connection for a skin rash on his thighs and testicles. He alleges that the disability's cause is service-connected discogenic disc disease of the lumbar spine. See September 2014 claim. He has also argued without specification that the disability is due to "service-connected disability." See NOD of June 2016. The Veteran has a rash in the groin area. See VA treatment record of August 2015. A service treatment record of May 1992 notes in illegible cursive several skin symptoms of the Veteran. On the separation examination report of June 1993, the Veteran responded negatively as to current or past skin diseases. Upon examination at that time, the Veteran was found to be normal with respect to the skin. In a mental health counseling session note of 2011, a social worker indicated that the Veteran attributed his groin rash to his urinary incontinence of the past two years and his use of adult diapers. See VA treatment record of April 2011. The Veteran is not service connected for a voiding disorder. VA has not secured a nexus opinion with respect to the Veteran's service-connection claim for a rash on the thighs and testicles. VA must provide a medical examination or opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the claimant's service or with another service-connected disability, but (4) the competent medical evidence on file is not sufficient for VA to make a decision on the claim. See 38 U.S.C. § 5103A(d) (2012); 38 C.F.R. § 3.159(c)(4) (2017). The third factor has been held to have a low threshold. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Under the low threshold standard of McLendon, a medical examination and opinion are needed to determine the likelihood of a nexus between the Veteran's current persistent or recurrent symptoms of a skin disorder and the skin symptoms noted during service in 1992. See 38 C.F.R. § 3.159(c)(4) (2017); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Bilateral Hip/Thigh Joint Condition The Veteran seeks service connection for a bilateral hip disability on the grounds that his service-connected pes planus causes him to walk unnaturally. See VA Form 9 of February 2017. The Veteran also argues without specification that the hip disability is due to a "service-connected disability." See NOD of June 2016. Various VA treatment records note the Veteran's complaint of shooting pain from the hips to the knees. See, e.g., VA treatment records of February 2008, February 2011, July 2013. A June 2010 VA treatment made an assessment of decreased length of hip musculature in conjunction with chronic back pain. A July 2010 VA treatment record diagnosed lower back pain and made an assessment of muscle guarding of lower back and hips/pelvis following treatment. A September 2013 VA treatment record notes that the Veteran appeared to have satisfactory flexion of both hips. VA back examinations of August 2015 and January 2017 found normal muscle strength for bilateral hip flexion. No hip symptoms are noted in the Veteran's service treatment records or on the exit examination of June 1993. The Veteran's service-connected disabilities include a low back disability and bilateral pes planus. Treatment records suggest that the Veteran's hip symptoms may be related to his back disability. A VA examination is required to determine the likelihood that the Veteran's recurrent hip symptoms are caused or aggravated by service or a service-connected disability, to include those of the back and feet. See 38 U.S.C. § 5103A(d) (2012); 38 C.F.R. § 3.159(c)(4) (2017); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding VA or private treatment records relating to the remanded claims. 2. Issue a SOC as to entitlement to a rating increase for the grant of service connection for unspecified depressive disorder, in response to the timely NOD that the Veteran filed in August 2017. 3. Issue a SOC as to the issue of entitlement to service connection for a sleeping disorder, to include sleep apnea, in response to the timely NOD that the Veteran filed in April 2013. The SOC should undertake a full legal analysis of the merits of the claim based on all relevant evidence of record. There is no requirement that the Veteran have submitted new and material evidence at any point following the rating decision of April 2013 that denied service connection. 4. Schedule the Veteran for a VA medical examination to assess the manifestations of his disability of the lumbar spine, including all neurological manifestations. The Veteran's virtual claims file must be made available for the examining doctor's review prior to the examination. All testing deemed necessary to rate the low back and associated radiculopathy under the criteria of the VA rating schedule must be conducted, and the results reported in detail. The examiner is asked to indicate the point during range-of-motion testing that motion is limited by pain. The examiner should test the range of motion in active motion, passive motion, weight-bearing, and non-weight-bearing for the back. If an examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should explain why. The examiner should describe the extent of any functional loss due to weakened movement, excess fatigability, incoordination, or pain on use, and should state whether any pain claimed by the Veteran is supported by adequate pathology and/or is evidenced by visible behavior such as facial expression or wincing. The examiner should express an opinion as to whether pain or other manifestations during flare-ups or with repeated use could significantly limit functional ability of the affected part. The examiner should portray the degree of any additional range-of-motion loss due to pain on repeated use or during flare-ups. If no estimate can be provided, the examiner should explain why. If the Veteran is not suffering from a flare-up of his back at the time of the examination, the examiner must attempt to ascertain information, such as frequency, duration, characteristics, severity, and functional loss, regarding any flare-ups by alternative means and to estimate the functional impact of any flare-ups in terms of range of motion on the basis of that information. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall 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). 5. Schedule the Veteran for a VA examination to determine the extent and severity of his service-connected bilateral pes planus. All necessary testing must be accomplished. The virtual claims folder must be made available for the examining doctor's review. All signs and symptoms of the Veteran's bilateral pes planus disabilities must be reported in detail. The examiner should express an opinion as to whether pain or other manifestations during flare-ups or with repeated use could significantly limit functional ability of the affected part. The examiner should portray the degree of any additional range-of-motion loss due to pain on repeated use or during flare-ups. If no estimate can be provided, the examiner should explain why. If the Veteran is not suffering from a flare-up of pes planus at the time of the examination, the examiner must attempt to ascertain information, such as frequency, duration, characteristics, severity, and functional loss, regarding any flare-ups by alternative means and to estimate the functional impact of any flare-ups in terms of range of motion on the basis of that information. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall 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). 6. Schedule the Veteran for a VA examination to assess the orthopedic manifestations of right shoulder injury, including all neurological manifestations. The Veteran's virtual claims file must be made available for the examining doctor's review. All testing necessary to rate the right shoulder and any associated disability under the criteria of the VA rating schedule must be conducted, and the results reported in detail. The examiner must indicate the point during range-of-motion testing that motion is limited by pain. The examiner should test the range of motion in active motion, passive motion, weight-bearing, and non-weight-bearing as appropriate. 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 explain why. The examiner should describe the extent of any functional loss due to weakened movement, excess fatigability, incoordination, or pain on use, and should state whether any pain claimed by the Veteran is supported by adequate pathology and/or is evidenced by visible behavior such as facial expression or wincing. The examiner should express an opinion as to whether pain or other manifestations during flare-ups or with repeated use could significantly limit functional ability of the affected part. The examiner should portray the degree of any additional range-of-motion loss due to pain on repeated use or during flare-ups. If no estimate can be provided, the examiner should provide a sufficiently detailed explanation as to why. If the Veteran is not suffering from a flare-up of his right shoulder disability at the time of the examination, the examiner must attempt to ascertain information, such as frequency, duration, characteristics, severity, and functional loss, regarding any flare-ups by alternative means and to estimate the functional impact of any flare-ups in terms of range of motion on the basis of that information. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall 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). 7. Schedule the Veteran for a VA medical examination with respect to the left knee and right knee. The claims file must be made available for review by the examining doctor. All indicated tests must be performed, and all findings reported in detail. The examiner is requested to set forth the appropriate diagnoses for the claimed disabilities and to opine as to whether it is at least as likely than as not (that is, a 50 percent probability or greater) that a disability of the left knee and/or right knee (found at any time since the filing of the Veteran's claim in September 2014, even if now resolved) is related to the Veteran's active service or to a service-connected disability. If it is determined that a current disability is at least as likely as not aggravated by a service-connected disability, the examiner should quantify the degree of aggravation; the examiner should identify the baseline level of severity prior to the onset of the aggravation, or by the earliest medical evidence at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity. A rationale for all expressed opinions must be set forth in the examination report. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall 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). 8. Schedule the Veteran for a VA medical examination with a doctor to determine the nature, extent, and etiology of all dermatological conditions since the filing of the Veteran's service connection claim in September 2014, including a rash on the thighs and/or testicles. The examination should be conducted during an exacerbation or active phase of the skin condition, if possible, in coordination with the Veteran. The electronic claims folder must be made available for the examiner's review. All indicated tests should be conducted, and all results reported in detail. The examiner is requested to set forth the appropriate diagnosis for the claimed disability and to opine as to whether it is at least as likely than as not (that is, a 50 percent probability or greater) that any current skin disability (found at any time since the filing of the Veteran's claim in September 2014, even if now resolved) is related to the Veteran's active service, to include skin symptoms noted during service in May 1992, or to a service-connected disability. If it is determined that a current disability is at least as likely as not aggravated by a service-connected disability, the examiner should quantify the degree of aggravation; the examiner should identify the baseline level of severity prior to the onset of the aggravation, or by the earliest medical evidence at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity. A rationale for all opinions expressed must be set forth in the examination report. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall 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). 9. Schedule the Veteran for a VA medical examination with respect to the bilateral hips and thighs. The claims file must be made available for review by the examining doctor. All indicated tests must be performed, and all findings reported in detail. The examiner is requested to set forth the appropriate diagnoses for the claimed disabilities and to opine as to whether it is at least as likely than as not (that is, a 50 percent probability or greater) that a disability of the hip(s) and/or thigh(s) (found at any time since the filing of the Veteran's claim in September 2014, even if now resolved) is related to the Veteran's active service or to a service-connected disability, to include disability of the low back and bilateral pes planus. If it is determined that a current disability is at as least as likely as not aggravated by a service-connected disability, the examiner should quantify the degree of aggravation; the examiner should identify the baseline level of severity prior to the onset of the aggravation, or by the earliest medical evidence at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity. A rationale for all opinions expressed must be set forth in the examination report. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall 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). 10. Undertake any warranted development with respect to the TDIU claim on appeal. 11. After completing the above action items to the extent possible, schedule the Veteran for a DRO hearing with respect to all remanded issues for which the Veteran has requested a DRO hearing. Notify the Veteran of the date, time, and location of the hearing, and add the notice letter to the Veteran's claims file. Add a summary or transcript of the DRO hearing to the Veteran's claim file. 12. After ensuring that the above development, and any other necessary development, has been completed to the extent possible, readjudicate the remanded claims. If any sought benefit remains denied, issue a supplemental statement of the case, and provide the Veteran with the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ G. A. Wasik Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs