Citation Nr: 18140180 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 15-06 544 DATE: October 2, 2018 ORDER The appeal to reopen service connection for bilateral status post varicose vein stripping is denied. New and material evidence having been received, the appeal to reopen service connection for left lower extremity saphenous neuralgia is granted. Service connection for left lower extremity saphenous neuralgia is denied. Service connection for right lower extremity saphenous neuralgia is denied. Service connection for hypertension is denied. Service connection for headaches is denied. The January 21, 1986 Department of Veterans Affairs (VA) Regional Office (RO) rating decision denying service connection for left lower extremity saphenous neuralgia was not clearly and unmistakably erroneous. The January 21, 1986 RO rating decision denying service connection for bilateral status post varicose vein stripping was not clearly and unmistakably erroneous. REMANDED Service connection for right hip osteoarthritis is remanded. Service connection for left hip osteoarthritis is remanded. Service connection for right ankle osteoarthritis is remanded. Service connection a left foot disorder is remanded. Service connection for a right foot disorder is remanded. Service connection for a sleep disorder is remanded. Service connection for an acquired psychiatric disorder, to include depression and alcohol and substance abuse, is remanded. An increased (compensable) disability rating for Achilles tendinitis of the left ankle is remanded. Entitlement to special monthly compensation based on the need for regular aid and attendance of another person or housebound status is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. A January 1986 rating decision denied service connection for bilateral status post varicose vein stripping, effectively finding that the disability clearly and unmistakably existed prior to service and clearly and unmistakably was not aggravated by service. The Veteran did not file a timely notice of disagreement (NOD) following the January 1986 rating decision, and no new and material evidence was received during the one year appeal period. 2. The evidence associated with the claims file subsequent to the January 1986 rating decision does not relate to an unestablished fact that is necessary to substantiate the claim for service connection for bilateral status post varicose vein stripping, or is cumulative and redundant of evidence previously of record. 3. A January 1986 rating decision denied service connection for left lower extremity saphenous neuralgia, finding that the Veteran did not have a current diagnosis of the disability at that time. The Veteran did not file a timely NOD following the January 1986 rating decision, and no new and material evidence was received during the one year appeal period. 4. New evidence received since the January 1986 rating decision relates to an unestablished fact of a current diagnosis of left lower extremity saphenous neuralgia. 5. The Veteran’s currently diagnosed left and right lower extremity saphenous neuralgia is due to the non service connected bilateral status post varicose vein stripping. 6. The Veteran is currently diagnosed with hypertension. 7. There was no cardiovascular injury or disease during service and symptoms of hypertension did not begin during active service and were not chronic in service. 8. Hypertension did not manifest to a compensable degree within one year of active service. 9. Symptoms of hypertension were not continuous since service. 10. The Veteran’s currently diagnosed headaches are due to the non service connected hypertension. 11. The evidence has not established, without debate, that the correct facts, as then known, were not before the RO at the time of the January 21, 1986 RO rating decision, or that the RO incorrectly applied the applicable laws or regulations existing at the time, when it denied service connection for left lower extremity saphenous neuralgia. 12. The evidence has not established, without debate, that the correct facts, as then known, were not before the RO at the time of the January 21, 1986 RO rating decision, or that the RO incorrectly applied the applicable laws or regulations existing at the time, when it denied service connection for bilateral status post varicose vein stripping. CONCLUSIONS OF LAW 1. The January 1986 rating decision denying service connection for bilateral status post varicose vein stripping became final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 2. Evidence received since the January 1986 rating decision is not new and material to reopen service connection for bilateral status post varicose vein stripping. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The January 1986 rating decision denying service connection for left lower extremity saphenous neuralgia became final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 4. Evidence received since the January 1986 rating decision is new and material to reopen service connection for left lower extremity saphenous neuralgia. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 5. Left lower extremity saphenous neuralgia was not incurred in active service and may not be presumed to have been incurred in active service. 38 U.S.C. §§ 1131, 1133, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.326(a) (2017). 6. Right lower extremity saphenous neuralgia was not incurred in active service and may not be presumed to have been incurred in active service. 38 U.S.C. §§ 1131, 1133, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.326(a) (2017). 7. Hypertension was not incurred in active service and may not be presumed to have been incurred in active service. 38 U.S.C. §§ 1131, 1133, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.326(a) (2017). 8. The criteria for service connection for headaches have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.326(a) (2017). 9. The January 21, 1986 rating decision denying service connection for left lower extremity saphenous neuralgia was not clearly and unmistakably erroneous. 38 U.S.C. § 5109A (2012); 38 C.F.R. § 3.105 (2017). 10. The January 21, 1986 rating decision denying service connection for bilateral status post varicose vein stripping was not clearly and unmistakably erroneous. 38 U.S.C. § 5109A (2012); 38 C.F.R. § 3.105 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, had active service from December 1983 to September 1985. This matter came before the Board of Veterans’ Appeals (Board) on appeal from a March 2012 rating decision of the RO in Decatur, Georgia. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). VA’s duties to notify and assist claimants under the VCAA do not apply to claims alleging clear and unmistakable error (CUE). Parker v. Principi, 15 Vet. App. 407 (2002); Livesay v. Principi, 15 Vet. App. 165, 179 (2001) (en banc). Therefore, no further discussion of VCAA duties to notify or assist will take place regarding the CUE issues on appeal. Additionally, no further discussion of VA’s duties to notify and assist is necessary as to the issues remanded in the instant decision. Concerning the duty to notify, the record reflects that the Veteran received adequate VCAA notice prior to the issuance of the March 2012 rating decision. Regarding the duty to assist, the record reflects that VA obtained all relevant documentation and provided the Veteran with an adequate VA examination concerning the remaining service connection issues on appeal in February 2011. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, the Board finds that the duties to notify and assist the Veteran in this case have been fulfilled. Neither the Veteran nor the evidence has raised any specific contentions regarding the duties to notify or assist. In various lay statements, the Veteran argued that hypertension, headaches, and right lower extremity saphenous neuralgia may be secondary to the Veteran’s service connected Achilles tendinitis of the left ankle. Having considered all the evidence of record, the Board does not find that a remand for an addendum opinion is necessary on the question of whether service connected Achilles tendinitis of the left ankle may have caused or aggravated currently diagnosed hypertension, headaches, and/or right lower extremity saphenous neuralgia. Competent lay or medical evidence is required to establish “an indication” that the advanced disabilities are related to the service connected Achilles tendinitis of the left ankle. See Waters v. Shinseki, 601 F.3d 1274, 1277-1278 (Fed. Cir. 2010); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony “falls short of satisfying the statutory standard” to “indicate” a disability “may be associated” with service). Nothing in the record suggests any relationship between the service connected Achilles tendinitis of the left ankle and hypertension, headaches, and/or right lower extremity saphenous neuralgia, and the Veteran offers neither competent lay evidence nor competent medical evidence to support the claim. Reopening of Service Connection Legal Authority Generally, a claim which has been denied may not thereafter be reopened and allowed based on the same record. 38 U.S.C. § 7105. However, pursuant to 38 U.S.C. § 5108, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the VA Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is “new and material,” the credibility of the new evidence must be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). 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). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly received evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Regardless of the RO’s determination as to whether new and material evidence had been received, the Board must address the issue of the receipt of new and material evidence in the first instance because it determines the Board’s jurisdiction to reach the underlying claims and to adjudicate the claims de novo. See Woehlaert v. Nicholson, 21 Vet. App. 456, 460-61 (2007) (citing Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996)). If the Board determines that the evidence submitted is both new and material, it must reopen the case and evaluate the claim in light of all the evidence. Justus, 3 Vet. App. at 512. Such evidence is presumed to be credible for the purpose of determining whether the case should be reopened; once the case is reopened, the presumption as to the credibility no longer applies. Id. at 513. Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996). Neuralgia (as other organic disease of the nervous system) and hypertension are chronic diseases under 38 C.F.R. § 3.309(a). As such, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on “chronic” symptoms in service and “continuous” symptoms since service are applicable to those issues. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Under 38 C.F.R. § 3.303(b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as “chronic” in 38 C.F.R. § 3.309(a). Walker, 708 F.3d at 1338-40 (holding that continuity of symptomatology is an evidentiary tool to aid in the evaluation of whether a chronic disease existed in service or an applicable presumptive period). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). In addition, the law provides that, where a veteran served ninety days or more of active service, and a chronic disease become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1133, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1111 (2012). Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b) (2017). Where such defects, infirmities or disorders are not noted when examined, accepted, and enrolled for service, pursuant to 38 U.S.C. § 1111 and 38 C.F.R. § 3.304, in order to rebut the presumption of soundness on entry into service, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); VAOPGCPREC 3-03. In explaining the meaning of an increase in disability, the United States Court of Appeals for Veterans Claims (Court) has held that “temporary or intermittent flare ups during service of a preexisting injury or disease are not sufficient to be considered ‘aggravation in service’ unless the underlying condition, as contrasted to symptoms, is worsened.” Hunt v. Derwinski, 1 Vet. App. 292, 297 (1992); see also Davis v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002) (explaining that, for non-combat veterans, a temporary worsening of symptoms due to flare ups is not evidence of an increase in disability). However, the increase need not be so severe as to warrant compensation. Browder v. Derwinski, 1 Vet. App. 204, 207 (1991). A veteran need not produce any evidence of aggravation in order to prevail under the no-aggravation prong of the presumption of soundness; rather, the burden is on VA to establish by clear and unmistakable evidence that it was not aggravated or that any increase in severity was due to the natural progress of the disease. Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). “The Federal Circuit has made clear that the Secretary may rebut the second prong of the presumption of soundness through demonstrating, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or (2) any increase in disability was due to the natural progression of the condition.” Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009) (citing Wagner, 370 F.3d at 1096). This burden must be met by “affirmative evidence” demonstrating that there was no aggravation. See Horn, 25 Vet. App. at 235. Conversely, the burden is not met by finding “that the record contains insufficient evidence of aggravation.” Id. Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a) (2012); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has thoroughly reviewed all the evidence in the Veteran’s claims file and adequately addresses the relevant evidence in the instant decision. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). 1. Whether New and Material Evidence was Received to Reopen Service Connection for Bilateral Status Post Varicose Vein Stripping The Veteran seeks service connection for bilateral status post varicose vein stripping residuals. Service treatment records, VA examination records, and the Veteran’s own lay statements all convey that the Veteran underwent a bilateral venous ligation stripping of the greater saphenous varicose veins prior to service in 1975. As the venous ligation stripping was not noted at service entrance, the presumption of soundness is implicated. As will be discussed in further detail in the CUE section below, a January 1986 rating decision denied service connection for bilateral status post varicose vein stripping, effectively finding that the disability clearly and unmistakably existed prior to service and clearly and unmistakably was not aggravated by service. The Veteran did not file a timely NOD following the January 1986 rating decision, and no new and material evidence was received during the one year appeal period following that decision. As such, the January 1986 rating decision became final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(a), (b), 20.302, 20.1103. Since the January 1986 rating decision, VA has received no new and material evidence indicating either that the varicose vein stripping was not performed prior to service or that any residuals of the procedure were aggravated during service. No VA or private treatment records have been received indicating the procedure took place after 1975, or that the residual symptoms of the procedure worsened during service. Further, during this appeal the Veteran’s main argument concerning service connection for bilateral status post varicose vein stripping is that the RO failed to adequately consider evidence found within a July 1985 medical board report, which was before the RO at the time of the January 1986 rating decision. While this argument is discussed in the CUE discussion below, it is not new and material evidence. Even considering the low evidentiary standard of Shade, no evidence has been received by VA that could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Shade, 24 Vet. App. at 118. For the reasons discussed above, the evidence associated with the claims file subsequent to the January 1986 rating decision does not relate to an unestablished fact that is necessary to substantiate the claim for service connection for bilateral status post varicose vein stripping, or is cumulative and redundant of evidence previously of record. As VA has not received both new and material evidence reflecting that the Veteran’s bilateral varicose vein stripping was not performed prior to service, or that any residuals of the procedure were aggravated during service, the issue may not be reopened. Under these circumstances, the Board finds that new and material evidence to reopen entitlement to service connection for bilateral status post varicose vein stripping has not been received. As such, the RO’s January 1986 rating decision remains final, and the appeal to reopen must be denied. As the evidence has not fulfilled the threshold burden of being new and material evidence to reopen the finally disallowed issue, the benefit of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). 2. Service Connection for Left and Right Lower Extremity Saphenous Neuralgia New and Material Evidence A January 1986 RO rating decision denied service connection for left lower extremity saphenous neuralgia, finding that the Veteran did not have a current diagnosis of the disability at that time. The Veteran did not file a timely NOD following the January 1986 rating decision, and no new and material evidence was received during the one year appeal period following that decision. As such, the January 1986 rating decision became final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(a), (b), 20.302, 20.1103. Since the January 1986 RO rating decision denying service connection for left lower extremity saphenous neuralgia, VA has received a February 2011 VA examination report indicating that the Veteran has a current diagnosis of left lower extremity saphenous neuralgia. Such evidence could substantiate the claim for service connection for left lower extremity saphenous neuralgia. As such, the Board finds that the additional evidence is new and material to reopen service connection for left lower extremity saphenous neuralgia. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Service Connection The Veteran seeks service connection for both left and right lower extremity saphenous neuralgia. Review of the evidence of record reflects that, per a February 2011 VA examination report, the Veteran is currently diagnosed with left and right lower extremity saphenous neuralgia. The report from the February 2011 VA medical examination reflects that the VA examiner thoroughly reviewed the evidence of record, including the Veteran’s service treatment records. At the conclusion of the examination, the VA examiner opined that the left and right lower extremity saphenous neuralgia was due to the non service connected venous ligation stripping of the greater saphenous varicose veins. This finding is supported by the report from a June 1985 in service medical board examination in which a service doctor opined that the Veteran had left saphenous neuralgia secondary to venous stripping. VA has not received any evidence contradicting the medical findings that the left and right lower extremity saphenous neuralgia is due to the non service connected venous ligation stripping of the greater saphenous varicose veins. The Board has given consideration to the Veteran’s contention that left and right lower extremity saphenous neuralgia is related to service. While the Veteran is competent to offer lay statements regarding observable symptoms in the lower extremities, such as pain and weakness, here, as a lay person, under the facts of this case, the Veteran does not have the requisite medical training or credentials to be able to render a competent medical opinion concerning whether the neuralgia is related to service. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (recognizing that lay competency is determined on a case by case basis); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). The Board has also considered whether service connection for left and right lower extremity saphenous neuralgia may be granted under 38 C.F.R. § 3.303(b) for chronic symptoms in service and/or continuous symptoms since service separation; however, 38 C.F.R. § 3.303(b) directs that service connection is not to be granted on this basis if the disability is clearly attributable to an intercurrent cause. Here, the evidence of record reflects that the left and right lower extremity saphenous neuralgia is due to the intercurrent non service connected venous ligation stripping of the greater saphenous varicose veins. As such, service connection cannot be granted on this basis. For these reasons, the Board finds that the weight of the evidence demonstrates that the Veteran’s currently diagnosed left and right lower extremity saphenous neuralgia are not related to service. Rather, the medical evidence of record indicates that the neuralgia is due to the non service connected venous ligation stripping of the greater saphenous varicose veins. As above, the Board has given consideration to the Veteran’s contention that the disabilities are related to service; however, the Veteran is a lay person and, while competent to discuss observable symptoms, does not have the requisite medical training or credentials to be able to render a competent opinion concerning neuralgia etiology. Because the preponderance of the evidence is against service connection, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Service Connection for Hypertension In the September 2010 service connection claim, the Veteran asserted that hypertension first manifested in service and is noted within the service treatment records. At the outset, the Board finds that the Veteran has a current diagnosis of hypertension. Such a diagnosis is found within the report of a February 2011 VA general medical examination. Pursuant to Diagnostic Code 7101, Note 1, for VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 millimeters (mm.) or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with diastolic blood pressure of less than 90 mm. 38 C.F.R. § 4.104 (2017). Service treatment records reflect that during service no diastolic blood pressure readings of 90 mm. or greater were recorded. In fact, most diastolic blood pressure readings were in the 70 mm. range. At the time of the service separation medical board examination in June 1985, the blood pressure reading was 120/72. For these reasons, the Board does not find that the diastolic blood pressure readings were “predominantly” 90 mm. or greater during service or at service separation. Additionally, the Board notes that no systolic blood pressure readings were recorded in excess of 126 mm. As such, the Board does not find that the Veteran’s systolic blood pressure was predominantly 160 mm. or greater during service. Further, the service treatment records reflect that the Veteran was not diagnosed with hypertension, or treated for high blood pressure, at any time during service. There is also no indication from the service treatment records that the Veteran had a cardiovascular injury or disease during service. Unfortunately, the Board has not received any evidence concerning when hypertension was first diagnosed. As such, the earliest diagnosis date the Board has is as of the February 2011 VA general medical examination. In the September 2010 claim, the Veteran did not advance being diagnosed with hypertension in service, merely that the service treatment records would support a finding that hypertension first manifested during service. The Veteran did state that over the years the hypertension “turned for the worst” and began impacting daily activities. Relatively the same statement was made in the February 2015 substantive appeal, via VA Form 9. After a review of all the evidence, lay and medical, the Board finds that a preponderance of the evidence is against a finding that the Veteran’s hypertension began in service, showed chronic symptoms in service, manifested to a compensable degree within one year of service, had continuous symptoms since service, or was caused by a cardiovascular disease or injury during service. Service treatment records reflect that the Veteran was not treated for hypertension in service, and the Board has not received any treatment records showing a diagnosis of hypertension prior to 2011. The Veteran underwent numerous blood pressure tests throughout service and was never diagnosed with hypertension. By the Veteran’s own admission, hypertension symptoms did not become significant until the years prior to 2011. Considering the evidence of record, as the Veteran’s last period of honorable service ended in September 1985, the evidence does not show that the currently diagnosed hypertension had its onset during service, or chronic symptoms in service, or manifested to a compensable degree within one year of service. The Board next finds the weight of the evidence demonstrates that symptoms of hypertension have not been continuous since service separation in September 1985. As noted above, the Veteran was not treated for, or diagnosed with, hypertension in service. The first recorded diagnosis of hypertension available to the Board was approximately 25 years after service separation, and by the Veteran’s own lay statements, it does not appear that symptoms first significantly manifested much earlier than that. The approximately 15 to 25 year period between service and the onset of hypertension is one factor that weighs against a finding of service incurrence, including by continuous symptoms since service from which service incurrence would be presumed. See Buchanan, 451 F.3d at 1336 (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical complaint of a claimed disability is one factor to consider as evidence against a claim of service connection). Additional factors weighing against continuous symptomatology since service include the numerous normal in service blood pressure readings, as context for post-service symptoms, and the Veteran’s own lay statements of no significant symptomatology until recent years. Although the Veteran has asserted that the currently diagnosed hypertension is related to service, she is a lay person and, under the facts of this particular case, does not have the requisite medical training or credentials to be able to render a competent opinion regarding this cause of the hypertension. The etiology of the Veteran’s hypertension is a complex medical question involving internal disease processes. Thus, while the Veteran is competent to report some hypertension symptoms experienced at any time, there are few observable symptoms of hypertension until hypertension is at a crisis stage, and some symptoms of hypertension such as dizziness or nosebleeds are common symptoms that overlap with symptoms of other disorders, so would require the ability to differentiate such symptoms attributable to hypertension from other common symptoms. For these reasons, under the facts of this case, the Veteran is not competent to opine on whether there is a link between the hypertension and service. See Kahana, 24 Vet. App. at 438 (recognizing that lay competency is determined on a case by case basis); Woehlaert, 21 Vet. App. at 462 (holding that rheumatic fever is not a condition capable of lay diagnosis). For these reasons, the Board finds that the weight of the evidence is against direct or presumptive service connection for hypertension under the provisions of 38 C.F.R. §§ 3.303, 3.307, and 3.309. As the preponderance of the evidence is against service connection, benefit of the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Service Connection for Headaches The Veteran asserts that currently diagnosed headaches are related to complaints of, and treatment for, headaches during service. At the outset the Board notes that the Veteran was diagnosed with headaches at the February 2011 VA general medical examination. An April 1985 service treatment record reflects that the Veteran complained of headaches three times per week. In February 2011 the Veteran received a VA general medical examination to assist in determining whether the currently diagnosed headaches were related to the complaints of headaches in service. After reviewing all the evidence of record, at the conclusion of the examination the VA examiner opined that the currently diagnosed headaches were caused by the non service connected hypertension. The Board notes that it has not received any treatment records or medical opinions contradicting this finding. The Board has given consideration to the Veteran’s contention that currently diagnosed headaches are related to the headaches complained of, and treated for, during service. While the Veteran is competent to offer lay statements regarding observable headache symptoms such as pain, here, as a lay person, under the facts of this case, the Veteran does not have the requisite medical training or credentials to be able to render a competent medical opinion concerning whether the current headaches are the same as those experienced during service, as headache causes can vary wildly. See Kahana, 24 Vet. App. 428 at 438 (recognizing that lay competency is determined on a case by case basis); Woehlaert v. Nicholson, 21 Vet. App. at 462 (holding that rheumatic fever is not a condition capable of lay diagnosis). For these reasons, the Board finds that the weight of the evidence demonstrates that the Veteran’s currently diagnosed headaches are not related to service, including the headache symptoms treated during service. A VA examiner specifically found that the Veteran’s current headaches are due to the non service connected hypertension. No medical evidence has been received that contradicts this finding. As above, the Board has given consideration to the Veteran’s contention that the current headaches are related to service; however, the Veteran is a lay person and, while competent to discuss observable symptoms, does not have the requisite medical training or credentials to be able to render a competent opinion as to headache etiology. Because the preponderance of the evidence is against service connection for headaches, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. CUE Legal Criteria Previous determinations that are final and binding, including decisions of service connection and other matters, will be accepted as correct in the absence of CUE. Where evidence establishes such error, the prior rating decision will be reversed or amended. For the purpose of authorizing benefits, the rating or other adjudicatory decision which constitutes a reversal of a prior decision on the grounds of CUE has the same effect as if the corrected decision had been made on the date of the reversed decision. 38 C.F.R. § 3.105(a). CUE is a very specific and rare kind of “error.” It is the kind of error, of fact or of law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error. Simply to claim CUE on the basis that previous adjudications had improperly weighed and evaluated the evidence can never rise to the stringent definition of CUE. Similarly, neither can broad-brush allegations of “failure to follow the regulations” or “failure to give due process,” or any other general, nonspecific claim of “error.” Fugo v. Brown, 6 Vet. App. 40, 43-44 (1993). In addition, failure to address a specific regulatory provision involves harmless error unless the outcome would have been manifestly different. Id. at 44. The Court has held that there is a three-pronged test to determine whether CUE is present in a prior determination: (1) “[e]ither the correct facts, as they were known at the time, were not before the adjudicator (i.e., more than a simple disagreement as to how the facts were weighed or evaluated) or the statutory or regulatory provisions extant at the time were incorrectly applied,” (2) the error must be “undebatable” and of the sort “which, had it not been made, would have manifestly changed the outcome at the time it was made,” and (3) a determination that there was CUE must be based on the record and law that existed at the time of the prior adjudication in question. Damrel v. Brown, 6 Vet. App. 242, 245 (1994) (quoting Russell v. Principi, 3 Vet. App. 310, 313-14 (1992) (en banc)). The Court has held that allegations that previous adjudications had improperly weighed and evaluated the evidence can never rise to the stringent definition of clear and unmistakable error. See Baldwin v. West, 13 Vet. App. 1, 5 (1999); Damrel, 6 Vet. App. at 246. If a veteran wishes to reasonably raise a claim of CUE, there must be some degree of specificity as to what the alleged error is and, unless it is the kind of error that, if true, would be CUE on its face, persuasive reasons must be given as to why one would be compelled to reach the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the alleged error. Bustos v. West, 179 F.3d 1378, 1381 (Fed. Cir. 1999), cert. denied, 528 U.S. 967 (1999); Fugo, 6 Vet. App. at 43-44. If the error alleged is not the type of error that, if true, would be CUE on its face, if the veteran is only asserting disagreement with how the RO evaluated the facts before it, or if the veteran has not expressed with specificity how the application of cited laws and regulations would dictate a “manifestly different” result, the claim must be denied or the appeal to the Board terminated because of the absence of legal merit or the lack of entitlement under the law. Luallen v. Brown, 8 Vet. App. 92 (1995); Caffrey v. Brown, 6 Vet. App. 377, 384 (1994). Further, VA’s failure in the duty to assist cannot constitute CUE. See Cook v. Principi, 318 F.3d 1334, 1346 (Fed. Cir. 2003). At the outset, the Board notes that the January 21, 1986, rating decision became final, as the Veteran did not file a timely NOD to the rating decision and no new and material evidence was received during the one year appeal period following that decision. See 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.156, 20.302, 20.1103 (2017). The Board also finds the allegations of CUE made by the Veteran are adequate to meet the threshold pleading requirements. See Simmons v. Principi, 17 Vet. App. 104 (2003); Phillips v. Brown, 10 Vet. App. 25 (1997) (distinguishing denial of CUE due to pleading deficiency and denial of CUE on merits). The Veteran in this matter is proceeding pro se. Although CUE motions must be pled specifically, a pro se motion must be read sympathetically, notwithstanding the specific pleading requirements set for in regulation. See Bowen v. Shinseki, 25 Vet. App. 250, 254 (2012). Further, the “manifestly changed outcome” pleading requirement may be inferred from pro se pleadings, even though not explicitly stated. See Canady v. Nicholson, 20 Vet. App. 393, 401-02 (2006). Having read the Veteran’s CUE pleadings, including a January 2011 pleading, the Board understands the Veteran’s CUE argument to be as follows. In its January 21, 1986 rating decision, the RO failed to consider evidence found within the report from the July 1985 in service medical board evaluation. Had such evidence been properly considered by the RO, the outcome would have been manifestly different, as service connection for both left lower extremity saphenous neuralgia and bilateral status post varicose vein stripping would have been granted. Under the law extant in 1986, service connection was warranted for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease in the line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 310 (1982). Additionally, it was stated that every veteran was in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, or enrollment, or where clear and unmistakable evidence (obvious or manifest) demonstrated that the injury or disease existed before acceptance and was not aggravated by such service. 38 U.S.C. § 311 (1982). A preexisting injury was considered to have been aggravated by active service where there was an increase in disability during such service, unless there was a specific finding that the increase in disability was due to the natural progress of the disease. 38 U.S.C. § 353 (1982) (now 38 U.S.C. § 1153). The applicable statute, 38 U.S.C. § 311 (now 38 U.S.C. § 1111), was implemented by 38 C.F.R. § 3.304(b) (1986), which provided that: The veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious and manifest) evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. The Federal Circuit clarified in Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004) that the presumption of soundness under 38 U.S.C. § 1111 is rebutted only if there is both (1) clear and unmistakable evidence that the claimed condition existed prior to service and (2) clear and unmistakable evidence that any preexisting conditions were not aggravated by service. If both prongs are satisfied then service connection will be denied. If either prong is not satisfied then the claim becomes one for direct service connection. Id. 5. Left Lower Extremity Saphenous Neuralgia The Veteran argues that service connection for left lower extremity saphenous neuralgia should have been granted in the January 21, 1986 RO rating decision because the disorder was diagnosed at the time of the of the July 1985 medical board evaluation. The Veteran received a VA general medical examination in December 1985. Per the examination report, the VA examiner reviewed the Veteran’s service records and performed a full physical examination. The examination report reflects that the Veteran was not displaying any left lower extremity saphenous neuralgia, and at the conclusion of the examination the Veteran was not diagnosed with left lower extremity saphenous neuralgia. As there was conflicting evidence of record at the time of the January 21, 1986 RO rating decision as to whether the Veteran had a current diagnosis of left lower extremity saphenous neuralgia, the Veteran’s argument that service connection should have been granted based upon the findings of the medical board in July 1985 appears to be nothing more than a disagreement with how the facts were weighed and evaluated, which is explicitly not CUE. Damrel, 6 Vet. App. at 245; Fugo, 6 Vet. App. at 43-44. Further, the Board notes that, even if the RO erred in failing to adequality consider the evidence found within the July 1985 medical board evaluation report, the evidence reflects that it is not undebatable that service connection would have been granted. The evidence of record, including the June 1985 medical board examination report, indicates that any neuralgia symptoms would have been related to the Veteran’s non service connected venous ligation stripping of the greater saphenous varicose veins. As reasonable minds could find that the left lower extremity saphenous neuralgia was due to the non service connected venous ligation stripping of the greater saphenous varicose veins, it cannot be said that it is undebatable that outcome would have manifestly changed, and service connection would have been granted. For the above reasons, the Board finds no CUE in the January 21, 1986 RO rating decision that denied service connection for left lower extremity saphenous neuralgia. 6. Bilateral Status Post Varicose Vein Stripping The Veteran argues that service connection for bilateral status post varicose vein stripping should have been granted in the January 21, 1986 RO rating decision based upon the findings of the medical board during service in July 1985. The Board notes that the medical board found both that the disorder preexisted service and was not aggravated by service. Service treatment records reflect that the disability of bilateral status post varicose vein stripping was not noted at service entrance; therefore, the presumption of soundness was at issue at the time of the January 21, 1986 RO rating decision. As discussed above, denial of service connection would have been warranted if there was clear and unmistakable evidence that the disability existed prior to service and that the bilateral status post varicose vein stripping was not aggravated by service. Review of the record reflects that service treatment records, including the July 1985 medical board evaluation, the report from the December 1985 VA general medical examination, and the Veteran’s lay statement both during service and prior to the January 21, 1986 RO rating decision, all contain evidence supporting a finding that there was clear and unmistakable evidence that the venous ligation stripping of the greater saphenous varicose veins took place prior to service in 1975. As such, any argument that the evidence reflects to the contrary would be nothing more than a disagreement with how the facts were weighed and evaluated, which is explicitly not CUE. Damrel, 6 Vet. App. at 245; Fugo, 6 Vet. App. at 43 44. As to the question of whether there was clear and unmistakable evidence that the bilateral status post varicose vein stripping was not aggravated by service, after reviewing the Veteran’s service treatment records and performing a thorough examination, the medical board in July 1985 found that the Veteran’s bilateral status post varicose vein stripping was not aggravated during service. Further, the VA examiner at the time of the December 1985 VA general medical examination found that the venous ligation stripping had been performed well with an excellent result, with no symptoms beyond scarring from the procedure. Nothing in the VA examination report indicates that the Veteran had any residual symptoms related to the varicose vein stripping that may have been aggravated by service. Again, any argument to the contrary appears to be nothing more than a disagreement with how the facts were weighed and evaluated, which is explicitly not CUE. Id. Having reviewed all the evidence of record, the Board finds that the evidence of record at the time of the January 21, 1986 RO rating decision was such that a reasonable mind could have found both that the disability of status post varicose vein stripping clearly and unmistakably preexisted service and that the disability clearly and unmistakably was not aggravated during service. As such, for the above reasons, the Board finds no CUE in the January 21, 1986 RO rating decision that denied service connection for bilateral status post varicose vein stripping. REASONS FOR REMAND 1. Service Connection for Right Hip Osteoarthritis 2. Service Connection for Left Hip Osteoarthritis 3. Service Connection for Right Ankle Osteoarthritis 4. Service Connection a Left Foot Disorder 5. Service Connection a Right Foot Disorder The Veteran received a VA general medical examination in February 2011. Per the examination report, the Veteran was to receive a separate VA foot examination conducted by podiatry. It does not appear that such an examination was ever performed. As such, the Board finds remand for a VA foot examination to be warranted. In multiple statements since the February 2011 VA general medical examination, the pro se Veteran has raised the theory of secondary service connection. Specifically, the Veteran contends that currently diagnosed hip, ankle, and foot disorders are due to the service connected Achilles tendinitis of the left ankle. While the Veteran did not specify how the service connected Achilles tendinitis of the left ankle may have caused one or more hip, ankle, and/or foot disorders, as the Veteran is pro se, the Board presumes that the Veteran is arguing that altered gait caused by the service connected Achilles tendinitis of the left ankle caused or aggravated one or more hip, ankle, and/or foot disorders. As such, the Board finds remand warranted for VA hip, ankle, and foot examinations.   6. Service Connection for a Sleep Disorder 7. Service Connection for an Acquired Psychiatric Disorder The Veteran has not received VA sleep disorder or mental health examinations during the pendency of this appeal. In the February 2015 substantive appeal, via VA Form 9, the Veteran advanced that sleep and psychiatric disorders are due to stress related to the Veteran’s early discharge from service due to medical conditions. As such, the Board finds remand for VA sleep disorder and mental health examinations to be warranted. 8. Increased Disability Rating for Achilles Tendinitis of Left Ankle A veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95. Since the February 2011 VA general medical examination, the Veteran has submitted multiple lay statements indicating that the symptoms of the Achilles tendinitis of the left ankle have worsened since the examination; therefore, the Board finds remand for a new VA ankle examination to be warranted. 9. Special Monthly Compensation Based on the Need for Regular Aid and Attendance of Another Person or Housebound Status 10. Entitlement to a TDIU The adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The remaining issues of entitlement to a TDIU and special monthly compensation will be affected by the development that occurs on the remanded issues; therefore, the issues are inextricably intertwined and must be remanded together. The aforementioned matters are REMANDED for the following action: 1. Contact the Veteran and request information as to any outstanding private treatment (medical) records concerning orthopedic, sleep, and mental health disorders. Upon receipt of the requested information and the appropriate releases, the AOJ should contact all identified health care providers and request that they forward copies of all available treatment records and clinical documentation for the relevant time period on appeal pertaining to the treatment of the disorders, not already of record, for incorporation into the record. If identified records are not ultimately obtained, the Veteran should be notified pursuant to 38 C.F.R. § 3.159(e). 2. Schedule the appropriate VA examinations. The relevant documents in the record should be made available to the examiners, who should indicate on the examination report that he/she has reviewed the documents in conjunction with the examination. A detailed history of relevant symptoms should be obtained from the Veteran. All indicated studies should be performed. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. The VA examiners should provide the following opinions: Bilateral Hip Osteoarthritis A) Is it at least as likely as not (50 percent or higher degree of probability) that the service connected Achilles tendinitis of the left ankle caused the currently diagnosed bilateral hip osteoarthritis? B) Is it at least as likely as not (50 percent or higher degree of probability) that the service connected Achilles tendinitis of the left ankle aggravated (that is, worsened in severity) the currently diagnosed bilateral hip osteoarthritis? Right Ankle A) Is it at least as likely as not (50 percent or higher degree of probability) that the service connected Achilles tendinitis of the left ankle caused the currently diagnosed right ankle osteoarthritis? B) Is it at least as likely as not (50 percent or higher degree of probability) that the service connected Achilles tendinitis of the left ankle aggravated (that is, worsened in severity) the currently diagnosed right ankle osteoarthritis? Foot Disorders A) Does the Veteran have a currently diagnosed right and/or left foot disorder? B) Is it at least as likely as not (50 percent or higher degree of probability) that a currently diagnosed right and/or left foot disorder is related to the lower extremity complaints and treatment during service? C) Is it at least as likely as not (50 percent or higher degree of probability) that the service connected Achilles tendinitis of the left ankle caused a currently diagnosed right or left foot disorder? D) Is it at least as likely as not (50 percent or higher degree of probability) that the service connected Achilles tendinitis of the left ankle aggravated (that is, worsened in severity) a currently diagnosed right or left foot disorder? Sleep Disorder A) Does the Veteran have a currently diagnosed sleep disorder? B) If the Veteran does have a currently diagnosed sleep disorder, is it at least as likely as not (50 percent or higher degree of probability) that the sleep disorder is related to stress caused by medical discharge from service? Acquired Psychiatric Disorder A) Does the Veteran have a currently diagnosed acquired psychiatric disorder? B) If the Veteran does have a currently diagnosed acquired psychiatric disorder, is it at least as likely as not (50 percent or higher degree of probability) that the psychiatric disorder is related to stress caused by the medical discharge from service? Achilles Tendinitis of Left Ankle The VA examiner should report the extent of all left ankle symptomatology in accordance with VA rating criteria. 3. Then, readjudicate the remaining issues on appeal. If any benefit sought on appeal remains denied, the Veteran and representative should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response before the case is returned to the Board. J. PARKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD E. Blowers, Counsel