Citation Nr: 18140808 Decision Date: 10/05/18 Archive Date: 10/05/18 DOCKET NO. 16-06 986 DATE: ORDER Entitlement to service connection for a left knee disability is denied. Entitlement to an initial compensable disability rating prior to December 15, 2015, and an initial disability rating in excess of 10 percent for a respiratory disability, to include chronic obstructive pulmonary disease and obstructive sleep apnea, thereafter, is denied. Entitlement to an initial compensable disability rating for hypertension is denied. Entitlement to an initial compensable disability rating for hemorrhoids is denied. Entitlement to an initial compensable disability rating for bilateral intention tremor of hands is denied. Entitlement to an effective date of August 17, 2011 for service connection for right lower extremity radiculopathy is granted. REMANDED Entitlement to service connection for right arm pain and numbness is remanded. Entitlement to service connection for fatty liver, claimed as an abdominal disability is denied. Entitlement to an initial disability rating in excess of 10 percent for a left wrist chronic sprain is remanded. Entitlement to an initial disability rating in excess of 20 percent for lumbar spine degenerative disc disease is remanded. Entitlement to a disability rating in excess of 10 percent for right knee degenerative joint disease is remanded. Entitlement to an initial disability rating in excess of 10 percent for right lower extremity radiculopathy is remanded. FINDINGS OF FACT 1. The competent evidence of record does not show a current diagnosis of a left knee disability. 2. Prior to December 15, 2015, the Veteran’s respiratory disability, to include chronic obstructive pulmonary disease and obstructive sleep apnea did not manifest in testing of FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; DLCO (SB) 66- to 80-percent predicted or persistent day-time hypersomnolence. 3. As of December 15, 2015, the Veteran’s respiratory disability, to include chronic obstructive pulmonary disease and obstructive sleep apnea does not manifest in testing of FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted or persistent day-time hypersomnolence. 4. The Veteran’s hypertension does not manifest in diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; diastolic pressure predominantly 100 or more, requiring continuous medication for control. 5. The Veteran’s hemorrhoids do not manifest in large or thrombotic, irreducible hemorrhoids, with excessive redundant tissue, evidencing frequent recurrences. 6. The Veteran’s bilateral intention tremor of hands does not manifest in incomplete, mild paralysis of the hands. 7. On August 17, 2011, VA received a claim for service connection for right leg pain and numbness, which was submitted within one year of his separation from service on April 27, 2011. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for an initial disability rating in excess of 10 percent for a respiratory disability, to include chronic obstructive pulmonary disease and obstructive sleep apnea have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.96, 4.119, Diagnostic Code (DC) 6604, 6847. 3. The criteria for an initial compensable disability rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.100, Diagnostic Code (DC) 7101. 4. The criteria for an initial compensable disability rating for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.110, Diagnostic Code (DC) 7336. 5. The criteria for an initial compensable disability rating for bilateral intention tremor of hands have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4120, Diagnostic Code (DC) 8099-8516. 6. The criteria for an effective date of April 28, 2011, for service connection for right lower extremity radiculopathy have been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.1, 3.151, 3.155, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1989 to September 1989 and from December 1998 to April 2011. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2012 rating decision and a July 2013 rating decision. The June 2012 rating decision, in part, granted the Veteran’s claims for service connection for lumbar spine degenerative disc disease, left wrist chronic sprain, right knee degenerative joint disease, chronic obstructive pulmonary disease, obstructive sleep apnea, hypertension, hemorrhoids. The rating decision assigned a 20 percent disability rating for lumbar spine degenerative disc disease, a 10 percent disability rating for left wrist chronic sprain, a 10 percent disability rating for right knee degenerative joint disease, and noncompensable disability ratings for obstructive pulmonary disease, obstructive sleep apnea, hypertension, and hemorrhoids. All disability ratings assigned are effective April 28, 2011. The rating decision also denied the Veteran’s claims for service connection for a left knee disability and for fatty liver. The July 2013 rating decision, in part, denied the Veteran’s claim for service connection for right arm pain and numbness and granted service connection for bilateral intention tremor of hands and assigned a noncompensable disability rating, effective April 28, 2011. A January 2016 rating decision granted service connection for right lower extremity radiculopathy and assigned a 10 percent disability rating, effective January 13, 2016. The rating decision also assigned a 10 percent disability rating for the Veteran’s service-connected respiratory disability, to include chronic obstructive pulmonary disease and obstructive sleep apnea, effective December 15, 2015. VA regulations prohibit separate evaluations for coexisting respiratory conditions, such as chronic obstructive pulmonary disease (Diagnostic Code 6604) and obstructive sleep apnea (Diagnostic Code 6847), and that a single rating had been assigned under the diagnostic code that reflected the predominant disability. See 38 C.F.R. § 4.96. The Board notes that the Veteran disagreed with the initial disability ratings assigned, and it is presumed he is seeking the highest possible rating or maximum benefits available under the law. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). Service Connection Service connection means that a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence shows that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or “medical nexus” between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004)); see 38 C.F.R. § 3.303(a). 1. Entitlement to service connection for a left knee disability is denied. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of a left knee disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton, 557 F.3d at 1366; Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). While the Veteran sustained a left knee injury during active service and underwent arthroscopic meniscal repair, there is no evidence of a link between the Veteran’s active service and a current left knee disability. The January 2016 VA examiner evaluated the Veteran and determined that there was no diagnosis concerning the left knee. The examination report indicates that range of motion testing was normal, there was no pain on weightbearing, no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, and no evidence of crepitus. The April 2012 VA examiner evaluated the Veteran and determined that there was no diagnosis concerning the left knee. The Veteran’s claim folder does not contain any additional evidence concerning a link between the Veteran’s active service and a current left knee disability. The Veteran’s VA treatment records indicate he utilizes a brace for his left knee, but does not provide a diagnosis for the left knee. The competent evidence of record does not reflect the presence of a functional disability of the left knee, to include one caused by pain. See Saunders v. Wilkie, 886 F.3d 1356, 1363 (Fed. Cir. 2018). In sum, the preponderance of the evidence weighs against service connection for a left knee disability. Consequently, the benefit-of-the-doubt rule does not apply and service connection for a left knee disability is denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. Increased Rating VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. See 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not “duplicative or overlapping with the symptomatology” of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be “staged” higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial-rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson, 12 Vet. App. at 126. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 2. Entitlement to an initial compensable disability rating prior to December 15, 2015, and an initial disability rating in excess of 10 percent for a respiratory disability, to include chronic obstructive pulmonary disease and obstructive sleep apnea, thereafter, is denied The Veteran’s chronic obstructive pulmonary disease is rated under Diagnostic Code 6604. A 10 percent rating is warranted for FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted. A 30 percent rating is warranted for FEV-1 of 56 to 70-percent predicted value, or; FEV-1/FVC of 56 to 70 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) is 56 to 65 percent predicted. A 60 percent rating is warranted for FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent rating is warranted for FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. 38 C.F.R. § 4.97. Ratings under diagnostic codes 6600 through 6817 and 6822 through 6847 will not be combined with each other. 38 C.F.R. § 4.96(a). When there is a disparity between the results of different Pulmonary Functions Tests (PFTs) (FEV-1, FVC, etc.), so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96(d)(6). Finally, if the FEV-1 and the FVC are both greater than 100 percent, a compensable evaluation based on a decreased FEV-1/FVC ratio should not be assigned. 38 C.F.R. § 4.96(d)(7). Concerning the time period prior to December 15, 2015, the Veteran underwent a VA examination in April 2012 that showed pre-bronchodilator of FEV-1/FVC of 91 percent and post-bronchodilator of FEV-1/FVC of 90 percent. There were no other PFTs conducted during this time period. VA treatment records from this time period do not reflect additional PFTs. Thus, prior to December 15, 2015, the Veteran’s chronic obstructive pulmonary disease did not meet the testing standards outlined with a compensable disability rating. Regarding the time period from December 15, 2015, forward, the Veteran underwent a VA examination on December 15, 2015 that showed pre-bronchodilator of FEV-1/FVC of 70 percent and post-bronchodilator of FEV-1/FVC of 71 percent. Thus, from December 15, 2015, the Veteran’s chronic obstructive pulmonary disorder warrants a 10 percent disability rating. There were no other PFTs conducted during this time period per the Veteran’s VA treatment records. Thus, for the time period from December 15, 2015, forward, the Veteran’s chronic obstructive pulmonary disease did not meet the testing standards outlined in the 30 percent disability rating. The Veteran’s obstructive sleep apnea is rated under Diagnostic Code 6847 (sleep apnea syndromes - obstructive, central, mixed). 38 C.F.R. § 4.97. Under Diagnostic Code 6847, a 30 percent rating is assigned for persistent day-time hypersomnolence. A 50 percent rating is assigned when the sleep apnea requires the use of a breathing assistance device such as CPAP machine. A maximum 100 percent rating is assigned for sleep apnea that causes chronic respiratory failure with carbon dioxide retention or cor pulmonale, or requires tracheostomy. Id. Concerning the time period prior to December 15, 2015, the Veteran underwent a VA examination in April 2012 that found no continuous use of medication required for control of his obstructive sleep apnea, no required use of a breathing assistance device, and no other findings, signs, or symptoms attributable to sleep apnea. Regarding the time period from December 15, 2015, forward, the Veteran underwent a December 2015 VA examination that showed the Veteran does not have any findings, signs, or symptoms attributable to sleep apnea. At no time during the entire appellate period has the Veteran’s obstructive sleep apnea manifested in persistent day-time hypersomnolence as reflected in his VA examinations, VA medical records, or lay statements and as such does not meet the 30 percent disability rating outlined in Diagnostic Code 6847. Therefore, the preponderance of the evidence weighs against entitlement to an initial compensable disability rating prior to December 15, 2015, and a disability rating in excess of 10 percent from December 15, 2015, thereafter. Consequently, the benefit-of-the-doubt rule does not apply and entitlement to an initial compensable disability rating prior to December 15, 2015, and a disability rating in excess of 10 percent from December 15, 2015, thereafter is denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 3. Entitlement to an initial compensable disability rating for hypertension is denied. The Veteran’s service-connected hypertension is currently assigned a noncompensable disability rating pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101. Note 3 to 38 C.F.R. § 4.104 provides that hypertension should be evaluated separately from hypertensive heart disease and other types of heart disease. Diagnostic Code 7101 pertains to hypertensive vascular disease (hypertension and isolated systolic hypertension). Under Diagnostic Code 7101, a 10 percent evaluation is assigned for diastolic pressure predominantly 100 or more; systolic pressure predominantly 160 or more; or, for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more; or, systolic pressure predominantly 200 or more. A 40 percent rating is appropriate for diastolic pressure predominantly 120 or more. A 60 percent rating is assigned for diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. Where the schedular criteria does not provide for a noncompensable evaluation, such an evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. There are three notes to 38 C.F.R. § 4.104, Diagnostic Code 7101. Note (1) provides that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure (i.e., bottom number) is predominantly 90 mm or greater, and isolated systolic hypertension means the systolic blood pressure (i.e., top number) is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. Note (2) requires the evaluation of hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. Note (3) states that hypertension should be evaluated separately from hypertensive heart disease and other types of heart disease. The Veteran underwent a VA examination for his hypertension in December 2015. At that examination, it was found that the Veteran’s current blood pressure readings were 164/94 in February 2015, 152/86 in December 2014, and 138/87 in April 2014. The examination report indicated that the average blood pressure reading for the Veteran was 151/89. It was also noted that the Veteran’s treatment plan called for taking continuous medication for his hypertension. The Veteran also underwent a VA examination for his hypertension in April 2012. At that examination, it was found that the Veteran’s current blood pressure readings were 126/84 for three readings in April 2012. The examination report indicates that the Veteran’s treatment plan called for taking continuous medication for his hypertension. The VA examination reports do not establish diastolic pressure predominantly 100 or more; systolic pressure predominantly 160 or more; or a history of diastolic pressure predominantly 100 or more with continuous medication for control. Therefore, a compensable disability rating is not shown based on the testing noted above. In sum, the preponderance of the evidence weighs against assignment of an initial compensable disability rating for hypertension. Consequently, the benefit-of-the-doubt rule does not apply and an initial compensable disability rating for hypertension is denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 4. Entitlement to an initial compensable disability rating for hemorrhoids is denied. The Veteran’s hemorrhoids are rated under Diagnostic Code 7336, which provides ratings for external and internal hemorrhoids. For mild or moderate hemorrhoids, a noncompensable rating is assigned. A 10 percent rating is assigned for large or thrombotic, irreducible hemorrhoids, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating assigned for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, Diagnostic Code (DC) 7336. The Veteran underwent a December 2015 VA examination, which demonstrates the Veteran’s treatment plan for hemorrhoids did not including taking continuous medication. The examination report noted that the Veteran has a history of mild or moderate external hemorrhoids, with no objective evidence of large, thrombotic or irreducible hemorrhoids, excessive or redundant tissue, frequent recurrences, persistent bleeding, or secondary anemia or fissures. There were no hemorrhoids found on examination. The Veteran also underwent an April 2012 VA examination. No physical examination was conducted as the Veteran declined testing. The examination report noted that the Veteran has findings, signs, or symptoms of mild or moderate external hemorrhoids. The examination report did not reveal objective evidence of large, thrombotic or irreducible hemorrhoids, excessive or redundant tissue, frequent recurrences, persistent bleeding, or secondary anemia or fissures. Therefore, the Board finds that the preponderance of the evidence shows Veteran’s hemorrhoids do not warrant a compensable disability rating under Diagnostic Code 7336 as the evidence of record does not reflect any findings of hemorrhoids that are large, thrombotic or irreducible or with excessive or redundant tissue, frequent recurrences, persistent bleeding, or secondary anemia or fissures. Consequently, the benefit-of-the-doubt rule does not apply and an initial compensable disability rating for hemorrhoids is denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 5. Entitlement to an initial compensable disability rating for bilateral intention tremor of hands is denied. The Veteran’s bilateral intention tremor of hands is rated by analogy to 38 C.F.R. § 4.124a, Diagnostic Code 8516, which pertains to paralysis of the ulnar nerve. Diagnostic Code 8516 provides ratings for complete and incomplete paralysis of the ulnar nerve, and ratings differ based on whether the minor or major extremity is being evaluated. In the January 2016 VA examination, the VA examiner noted that the Veteran was right-hand dominant. Therefore, for the purposes of evaluating the Veteran’s bilateral cubital intention tremor of hands, his right upper extremity will be considered the major extremity and his left upper extremity will be considered the minor extremity. See 38 C.F.R. § 4.59 (handedness, for the purpose of VA ratings, will be determined by the evidence of record and only one hand may be considered dominant). Under Diagnostic Code 8516, mild incomplete paralysis is rated 10 percent disabling for both the minor and major extremity; moderate incomplete paralysis is rated 30 percent disabling for the major extremity and 20 percent disabling for the minor extremity; and severe incomplete paralysis is rated 40 percent disabling for the major extremity and 30 percent disabling for the minor extremity. Complete paralysis is rated as 60 percent disabling for the major extremity and 50 percent disabling for the minor extremity. Complete paralysis is exemplified by symptoms such as the “griffin claw” deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of tension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; and flexion of the wrist weakened. The term “incomplete paralysis,” with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124a. The terms “mild,” “moderate,” and “severe” are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The January 2016 VA examiner noted that the Veteran has a slight intention tremor when holding his hand out in front of him, with no deficits in hand dexterity or functional limitations noted on examination. The examination report also shows that the tremor is not present at rest. The examination report did not indicate that there was incomplete paralysis of the Veteran’s hands. The Veteran’s VA treatment records also do not demonstrate evidence of mild incomplete paralysis of the Veteran’s hands. Therefore, the Board finds that the preponderance of the evidence shows Veteran’s bilateral intention tremor of hands rated under Diagnostic Code 8516 does not result in mild incomplete paralysis. Consequently, the benefit-of-the-doubt rule does not apply and an initial compensable disability rating for bilateral intention tremor of hands is denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. Earlier Effective Date Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. If a claim for disability compensation is received within one year after separation from service, the effective date of entitlement is the day following separation or the date entitlement arose. 38 C.F.R. § 3.400(b)(2). Otherwise, it is the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. Furthermore, the terms “claim” or “application” mean a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). The VA administrative claims process recognizes formal and informal claims. A formal claim is one that has been filed in the form prescribed by VA. 38 C.F.R. § 3.151(a). An informal claim may be any communication or action indicating intent to apply for one or more benefits under VA law. See Thomas v. Principi, 16 Vet. App. 197 (2002); see also 38 C.F.R. 3.1(p), 3.155(a). An informal claim must be written and must identify the benefit being sought. See Rodriguez v. West, 189 F. 3d. 1351 (Fed. Cir. 1999); Brannon v. West, 12 Vet. App. 32, 34-35 (1998). To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). 6. Entitlement to an effective date prior to January 13, 2016 for service connection for right lower extremity radiculopathy is granted. The Veteran was discharged from active service in April 2011. VA received the Veteran’s formal application for service connection for right leg pain and numbness on August 17, 2011. In the January 2016 rating decision, VA granted service connection for right lower extremity radiculopathy, claimed as right leg pain and numbness and assigned a 10 percent disability rating, effective January 13, 2016. This claim was received within one year after separation from active service on April 27, 2011. See 38 C.F.R. § 3.400(b)(2)(i). Accordingly, entitlement to an effective date prior to January 13, 2016, for service connection for right lower extremity radiculopathy, is granted. Because the claim was received within one year after separation from active service, the effective date for service connection for right lower extremity radiculopathy is April 28, 2011—the day following separation. Id. Because the law, and not the facts, is dispositive of the outcome of this issue, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Sabonis v. West, 6 Vet. App. 426, 430 (1994). REASONS FOR REMAND 1. Entitlement to service connection for right arm pain and numbness is remanded. Because there is at least an indication that the Veteran’s current right arm pain and numbness may be related to his active duty service, a VA examination and opinion must be provided to make an informed decision on this claim. See McLendon v. Nicholson, 20 Vet. App.79, 83 (2006); see also Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (the Board is not competent to substitute its own opinion for that of a medical expert). VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon, 20 Vet. App. at 83. The threshold for determining whether the evidence “indicates” that there “may” be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon, 20 Vet. App. at 83. The Veteran’s service treatment records in October 2009 shows treatment to the Veteran’s neck and trapezius bilaterally. Additionally, the Veteran currently complains of right arm pain and numbness that is related to his service-connected lumbar spine degenerative disc disease. See September 2013 Notice of Disagreement (NOD). The above threshold having been met of evidence that may indicate a nexus between a current disability and an in-service event, injury, or disease, a VA examination and opinion must be provided to make an informed decision on the Veteran’s claim for service connection for right arm pain and numbness. 2. Entitlement to service connection for fatty liver, claimed as an abdominal disability is remanded. The April 2012 VA Hepatitis, Cirrhosis, and other Liver Conditions Examination is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA medical opinion, it must ensure that the examination or opinion is adequate); D’Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination must be based on consideration of the claimant’s medical history and must describe the disability in sufficient detail so that the Board’s evaluation of the disability will be a fully informed one). The examination report does not demonstrate that a medical opinion was provided concerning the link between the Veteran’s active service and his current diagnosed fatty liver. A VA examination and medical opinion must be provided to make an informed decision on the Veteran’s claim for service connection for fatty liver. 3. Entitlement to an initial disability rating in excess of 10 percent for a left wrist chronic sprain is remanded. The January 2016 VA Wrist Conditions Examination is inadequate. See Barr, 21 Vet. App. at 312; D’Aries, 22 Vet. App. at 104. A new VA examination must be provided to comply with Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). The United States Court of Appeals for Veterans Claims (the Court), held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weightbearing and non-weightbearing and, if possible, with range of motion measurements of the opposite undamaged joint, or an explanation as to why such testing is not warranted or not possible. See Correia, 28 Vet. App. at 158. The January 2016 examination report does not specify that passive and non-weightbearing range of motion testing was performed, or whether such testing was considered not warranted or not possible. Additionally, VA examiners are required to obtain information from the Veteran as to the severity, frequency, and duration of flare-ups, as well as precipitating and alleviating factors, and the extent of functional impairment. Sharp, 29 Vet. App. at 32. The January 2016 examination report indicates that the Veteran reports left wrist soreness, and flare-ups of left wrist pain during certain twisting or gripping movements. VA examiners are also required to estimate the additional loss of range of motion during a flare-up based on all procurable information from the record, as well as the Veteran’s own statements. Id. at 34-35. If an estimate cannot be provided without resort to speculation, it must be clear whether this is due to a lack of knowledge among the medical community at large, or insufficient knowledge of the specific examiner. Id. at 36. In this case, the January 2016 examination report does not provide the necessary information regarding flare-ups, as specified above. Although the examination was not performed during a flare-up, it is not apparent why the examiner could not estimate additional functional loss based on the Veteran’s statements describing the flare-ups, or why the available information in the file was not sufficient to permit such an estimate. The April 2012 VA Wrist Conditions Examination demonstrates that the contributing factors to functional loss, functional impairment, and/or additional limitation of range of motion experienced by the Veteran is pain on movement. The August 2012 Notice of Disagreement (NOD) notes the Veteran is unable to rotate his left wrist away from his body, or perform extension or flexion of the left wrist without experiencing severe pain. Thus, a retrospective medical opinion is necessary to capture the severity and functional impact of the Veteran’s left wrist chronic sprain for the entire appeal period. See Chotta v. Peake, 22 Vet. App. 80 (2008) (when there is an absence of medical evidence during a certain period of time, a retroactive medical evaluation may be warranted). 4. Entitlement to an initial disability rating in excess of 20 percent for lumbar spine degenerative disc disease is remanded. The January 2016 VA Back (Thoracolumbar Spine) Examination is inadequate. See Barr, 21 Vet. App. at 312; D’Aries, 22 Vet. App. at 104. The January 2016 examination report does not specify that passive and non-weightbearing range of motion testing was performed, or whether such testing was considered not warranted or not possible as is required. See Correia, 28 Vet. App. at 158. Additionally, the January 2016 examination report indicates that the Veteran experiences low back pain as constant, sharp, stabbing pain, which radiates into both buttocks and is worse when bending over, lying flat, or leaning over. However, the January 2016 examination report does not contain information concerning the severity, frequency, and duration of flare-ups, as well as precipitating and alleviating factors, and the extent of functional impairment. Sharp, 29 Vet. App. at 32. The April 2012 VA Back (Thoracolumbar Spine) Examination noted that the Veteran reported daily flare-ups. The examination report shows that the contributing factors to functional loss, functional impairment, and/or additional limitation of range of motion as pain on movement. The August 2012 Notice of Disagreement (NOD) provides that he cannot bend down to put his shoes on, and has severe pain and muscle spasms or cramps when he rotates his trunk. Thus, a retrospective medical opinion is necessary to capture the severity and functional impact of the Veteran’s flare-ups on his lumbar spine degenerative disc disease for the entire appeal period. See Chotta, 22 Vet. App. 80. 5. Entitlement to a disability rating in excess of 10 percent for right knee degenerative joint disease is remanded. The January 2016 VA Knee and Lower Leg Conditions Examination is inadequate. See Barr, 21 Vet. App. at 312; D’Aries, 22 Vet. App. at 104. The January 2016 examination report shows that there is pain on weightbearing, it does not specify that passive and non-weightbearing range of motion testing was performed, or whether such testing was considered not warranted or not possible as is required. See Correia, 28 Vet. App. at 158. Also, the January 2016 examination report shows that the Veteran reported right knee grinding and popping with pain and that he experiences flare-ups of right knee pain when bending his knee or squatting. But, the January 2016 examination report does not contain information concerning the severity, frequency, and duration of flare-ups, as well as precipitating and alleviating factors, and the extent of functional impairment. Sharp, 29 Vet. App. at 32. The April 2012 VA Knee and Lower Leg Conditions Examination noted the Veteran reports flare-ups during prolonged sitting, standing, and walking. The examination report shows that the contributing factors to functional loss, functional impairment, and/or additional limitation of range of motion as pain on movement. The August 2012 Notice of Disagreement (NOD) states that the Veteran has no strength in his right knee, experiences constant pain, and if he bends down, he cannot rise back up. The NOD also provides that the Veteran feels popping, catching, and “moving back and forth just above his right knee cap.” Thus, a retrospective medical opinion is necessary to capture the severity and functional impact of the Veteran’s flare-ups on his right knee degenerative joint disease for the entire appeal period. See Chotta, 22 Vet. App. 80. 6. Entitlement to an initial disability rating in excess of 10 percent for right lower extremity radiculopathy is remanded. A decision on the claim for lumbar spine degenerative disc disease could affect the Veteran’s claim for an initial disability rating for right lower extremity radiculopathy. See 38 C.F.R. § 4.16(a); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Accordingly, it must be remanded as well. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from January 2017 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for the Dayton Pain Clinic or any other physician or facility adequately identified by the Veteran. Make two requests for the authorized records from the Dayton Pain Clinic or any other physician or facility adequately identified by the Veteran, unless it is clear after the first request that a second request would be futile. 3. After the above development is completed, schedule the Veteran for an examination by an appropriate clinician(s) to determine the nature and etiology of any right arm pain and numbness and fatty liver. (a.) The examiner must opine whether the Veteran’s right arm pain and numbness is at least as likely as not related to an in-service injury, event, or disease. (b.) The examiner must opine whether it is at least as likely as not (1) proximately due to service-connected lumbar spine degenerative disc disease, or (2) aggravated beyond its natural progression by service-connected lumbar spine degenerative disc disease. 4. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 5. Schedule the Veteran for an examination of the current severity of his left wrist chronic sprain, lumbar spine degenerative disc disease, and right knee degenerative joint disease. Left wrist chronic sprain: (a.) The examiner must test the Veteran’s active motion, passive motion, and pain with weightbearing and without weightbearing. If the examiner is unable to conduct one or more of the above tests or finds that it is unnecessary, the examiner must provide an explanation. In any event, the type of test performed (i.e. active or passive, weightbearing or non-weightbearing), must be specified. (b.) The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. (c.) To the extent possible, the examiner should identify any symptoms and functional impairments due to left wrist chronic sprain alone and discuss the effect of the Veteran’s left wrist chronic sprain on any occupational functioning and activities of daily living. (d.) The examiner should also provide a retrospective opinion, as best as can be ascertained from the Veteran’s self-reports as well as from clinical records and other evidence, for the April 2012 and January 2016 examinations. For each examination, the examiner is asked to provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. Lumbar spine degenerative disc disease: (e.) The examiner must test the Veteran’s active motion, passive motion, and pain with weightbearing and without weightbearing. If the examiner is unable to conduct one or more of the above tests or finds that it is unnecessary, the examiner must provide an explanation. In any event, the type of test performed (i.e. active or passive, weightbearing or non-weightbearing), must be specified. (f.) The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. (g.) To the extent possible, the examiner should identify any symptoms and functional impairments due to lumbar spine degenerative disc disease alone and discuss the effect of the Veteran’s lumbar spine degenerative disc disease on any occupational functioning and activities of daily living. (h.) The examiner should also provide a retrospective opinion, as best as can be ascertained from the Veteran’s self-reports as well as from clinical records and other evidence, for the April 2012 and January 2016 examinations. For each examination, the examiner is asked to provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. Right knee degenerative joint disease: (i.) The examiner must test the Veteran’s active motion, passive motion, and pain with weightbearing and without weightbearing. If the examiner is unable to conduct one or more of the above tests or finds that it is unnecessary, the examiner must provide an explanation. In any event, the type of test performed (i.e. active or passive, weightbearing or non-weightbearing), must be specified. (j.) The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. (k.) To the extent possible, the examiner should identify any symptoms and functional impairments due to right knee degenerative joint disease alone and discuss the effect of the Veteran’s right knee degenerative joint disease on any occupational functioning and activities of daily living. (l.) The examiner should also provide a retrospective opinion, as best as can be ascertained from the Veteran’s self-reports as well as from clinical records and other evidence, for the April 2012 and January 2016 examinations. For each examination, the examiner is asked to provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Mussey, Associate Counsel