Citation Nr: 18142397 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 15-21 035 DATE: October 15, 2018 ORDER New and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disorder. Entitlement to service connection for hearing loss is denied. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to secondary service connection for a kidney disorder is denied. Entitlement to a rating in excess of 10 percent for diabetes mellitus, type II, (diabetes) is denied. Entitlement to an initial rating in excess of 10 percent for left carpal tunnel syndrome is denied. Entitlement to an initial rating in excess of 10 percent for right carpal tunnel syndrome is denied. Entitlement to an effective date of May 12, 2010, for the award of special monthly compensation based on loss of use of a creative organ is granted. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to secondary service connection for an eye disorder is remanded. Entitlement to service connection for a bilateral upper extremity muscle disability is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is remanded. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded.   FINDINGS OF FACT 1. A June 1971 rating decision denied service connection for a nervous condition; the Veteran did not appeal that decision, and new and material evidence was not received within one year of notice of its issuance. 2. Evidence received more than one year since the June 1971 rating decision is neither cumulative nor redundant of evidence already of record, and raises a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder. 3. The Veteran does not have current hearing loss in either ear to an extent recognized as a disability for VA purposes. 4. The Veteran’s tinnitus is related to in-service acoustic trauma. 5. The Veteran’s cervical spine disability was not incurred during active duty and is not otherwise related to military service; degenerative disc disease of the cervical spine did not manifest to a compensable degree within one year of separation from service. 6. The Veteran’s sleep apnea was not incurred during active duty and is not otherwise related to military service. 7. The Veteran does not have a current kidney disorder. 8. The Veteran’s diabetes has been managed by restricted diet alone throughout the period on appeal. 9. The Veteran’s left carpal tunnel syndrome has been manifested by no more than mild incomplete paralysis of the median nerve during the appeal period. 10. The Veteran’s right carpal tunnel syndrome has been manifested by no more than mild incomplete paralysis of the median nerve during the appeal period. 11. On May 12, 2010, VA received the Veteran’s claim of entitlement to service connection for diabetes. As part of that claim, the issue of special monthly compensation for loss of use of a creative organ was raised, but not adjudicated. CONCLUSIONS OF LAW 1. The June 1971 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. The criteria to reopen the claim of entitlement to service connection for an acquired psychiatric disorder are met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for entitlement to service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R §§ 3.102, 3.303, 3.307, 3.309, 3.385. 4. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for entitlement to service connection for a cervical spine disability are not met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for entitlement to service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for entitlement to service connection for a kidney disorder are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 8. The criteria for a rating in excess of 10 percent for diabetes are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.119, Diagnostic Code (DC) 7913. 9. The criteria for an initial rating in excess of 10 percent for left carpal tunnel syndrome are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.124a, DC 8515. 10. The criteria for an initial rating in excess of 10 percent for right carpal tunnel syndrome are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.124a, DC 8515. 11. The criteria for an effective date of May 12, 2010, for the award of special monthly compensation based on loss of use of a creative organ are met. 38 U.S.C. § 1114, 5110; 38 C.F.R. §§ 3.400, 3.350, 4.119. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1969 to January 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from January 2015 and August 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Board has recharacterized the Veteran’s claims as reflected on the title page to ensure consideration of all diagnoses of record. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). New and Material Evidence 1. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for an acquired psychiatric disorder. A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of the decision, or new and material evidence is received during the appeal period after the decision. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.302, 20.1103. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108; see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New evidence is defined as existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 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). The Veteran’s initial claim of entitlement to service connection for a psychiatric disorder (claimed as a nervous condition) was denied in a June 1971 rating decision, based on the finding of no current disorder. The Veteran did not appeal this decision, and new and material evidence was not received within one year of its issuance. Accordingly, the June 1971 rating decision is final, and new and material evidence is required to reopen the claim. See 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156(b), 20.1103; Buie v. Shinseki, 24 Vet. App. 242 (2010). Evidence received more than one year since the June 1971 rating decision includes a March 2014 medical report from Dr. Mora Quesada relating the Veteran’s diagnosed psychiatric disorders to service. This evidence is new, as it was not considered in the prior denial. It is also material, because it is not cumulative or duplicative of evidence previously considered and it raises a reasonable possibility of substantiating the claim. As such, the Veteran has presented new and material evidence to reopen the previously denied claim of entitlement to service connection for an acquired psychiatric disorder. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Certain chronic disabilities, including sensorineural hearing loss, tinnitus, and arthritis, are presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). The option of establishing service connection through a demonstration of continuity of symptomatology is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 1. Entitlement to service connection for hearing loss. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of those frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran’s in-service noise exposure is not in dispute. However, the Board finds that service connection for bilateral hearing loss is not warranted because no current hearing disability exists. The United States Court of Appeals for Veterans Claims has held that the current disability requirement is satisfied when a claimant “has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim,” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), or “when the record contains a recent diagnosis of disability prior to... filing a claim for benefits based on that disability.” Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). Neither of these criteria is met. The Veteran filed his claim for service connection for hearing loss in March 2014, and there is no evidence of a diagnosis of bilateral hearing loss for VA purposes in the evidence dated prior to or at the time of the filing of his claim. Furthermore, none of his in-service audiograms or examinations demonstrate hearing loss for VA purposes. The Veteran’s was afforded a VA examination in August 2014. Speech audiometry revealed a Maryland CNC speech discrimination score of 100 percent in both ears, and revealed the following pure tone thresholds, in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 15 20 25 LEFT 15 15 15 20 20 These findings do not demonstrate bilateral hearing loss for VA compensation purposes. 38 C.F.R. § 3.385. Moreover, given the lack of current hearing loss, to include within the one-year period following service separation, presumptive service connection is not available. 38 C.F.R. §§ 3.303(b), 3.307(a), 3.309(a). The Veteran’s VA treatment records reflect that an audiological evaluation was performed in September 2013. However, the evaluation employed word recognition testing and did not include Maryland CNC controlled speech discrimination tests. Therefore, this evaluation is inadequate for VA rating purposes and cannot be utilized to evaluate the Veteran’s hearing loss. Regardless, the examining audiologist indicated normal hearing with the exception of decreased hearing at 8000 Hz in the right ear and 6000 Hz and 8000 Hz in the left ear, which is similar to the findings in the August 2014 VA examination report and is not demonstrative of any hearing impairment for VA purposes (pure tone thresholds do not meet VA’s criteria for a diagnosis of hearing loss). To the extent the Veteran asserts that he has bilateral hearing loss, although he is competent to report the symptoms he observes, such as decreased hearing ability, he is not competent to report that he has a hearing loss disability, because such a determination requires specific audiometric findings. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, as the first element of service connection is not met at any point during the appeal period, the claim fails on this basis alone. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (in the absence of proof of present disability there can be no successful claim); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (also interpreting 38 U.S.C. § 1131 as requiring the existence of a present disability for VA compensation purposes). 2. Entitlement to service connection for tinnitus. Here, there is conflicting evidence as to the presence of current tinnitus. The August 2014 VA examiner noted the Veteran did not report any current tinnitus. However, the Veteran has competently reported tinnitus in his lay submissions and to Dr. Mora Quesada, and his VA treatment records show a diagnosis of tinnitus. See March 2014 private treatment record; see also January 2015 VA treatment record. In this regard, tinnitus is a disorder that is readily observable by laypersons and does not require medical expertise to establish its existence. See Charles v. Principi, 16 Vet. App. 370 (2002). Affording the Veteran the benefit of the doubt, a current disability is established. Moreover, even though his service treatment records are silent for reports of tinnitus in service, the second element required for direct service connection has also been satisfied, as in-service acoustic trauma as reported by the Veteran is consistent with the circumstances of his combat service. 38 U.S.C. § 1154(b). Finally, the Veteran relates his tinnitus to his conceded in-service acoustic trauma and is competent to do so, and his nexus statement is supported by Dr. Mora Quesada. As the only nexus opinions of record are in favor of the claim, all three elements are met, and service connection is established. 3. Entitlement to service connection for a cervical spine disability. 4. Entitlement to service connection for sleep apnea. As issues 3-4 are related, the Board will address them together. Regarding the first element of service connection, the Veteran has current diagnoses of sleep apnea and cervical degenerative disc disease with spinal canal stenosis. See August 2014 VA examination reports. Accordingly, the first element is established. Turning to the second element, in-service incurrence of a disease or injury, the Veteran does not report, nor do his service treatment records identify any complaints, treatment for, or diagnosis associated with the cervical spine or sleep problems, or symptoms indicative of the same. At service separation in January 1971, clinical evaluation of the neurologic, psychiatric, spine and other musculoskeletal systems were normal, and the Veteran did not endorse any such complaints. Here, the separation examination is the type regularly kept for this purpose. Furthermore, by its very nature, this separation examination, including the questions asked on the medical history questionnaire form, was intended to be a comprehensive accounting of the Veteran’s past medical history. Because it does not indicate the presence of any relevant complaints or findings, the Veteran’s separation examination must be accepted as the credible and accurate account of his condition during service. Therefore, it provides affirmative evidence that there was no continuous complaints or abnormality during service, including at service separation. To the extent the Veteran now indicates in-service symptomatology, the Board affords more probative value to the negative service treatment records, the lack of any indication of any cervical spine or sleep problems in the record for decades after service, and the Veteran’s own reports to the August 2014 VA examiner detailed below, than to his statements in conjunction with his claim for benefits. As such, element two is not met, and the claim fails on this basis alone. Additionally, there is no evidence that the Veteran’s cervical spine arthritis manifested to a compensable degree within a year of service to allow for presumptive service connection for a chronic disease. Instead, the first evidence of degenerative disc disease is decades after service. For similar reasons, a nexus through a continuity of symptomatology is not available. Regarding the last element, nexus, the only probative opinion of record is against the claim. Specifically, the August 2014 VA examiner opined that it was less likely than not that the Veteran’s cervical spine disability and sleep apnea were related to service. The examiner reasoned that the Veteran did not have any incidences of cervical pain or sleep trouble during service. Moreover, and critically, the examiner highlighted the fact that the Veteran reported to him that he first underwent a sleep study in 2011, after complaining about daytime sleepiness, loud snoring, waking up with a choking sensation, and feeling tired, decades after service. The examiner also reasoned that the evidence of record (e.g. lack of cervical spine symptoms and diagnosis for decades after service) did not support a direct nexus for a cervical spine disability, and attributed it to the normal aging process. This opinion is highly probative, as it was rendered based on an interview and physical examination of the Veteran, considers the Veteran’s pertinent medical history, and is sufficiently rationalized on the evidence of record. There is no probative opinion to the contrary. A private doctor gave a positive opinion in February 2014. However, this opinion was a bare conclusion with no supporting rationale. An unexplained conclusory opinion, such as this, is entitled to no weight in a service-connection context. Horn v. Shinseki, 25 Vet. App. 231, 240 (2012). To the extent that the Veteran asserts that his cervical spine disability and sleep apnea are the result of his active duty service, the Board finds that the determination as to the etiology of such disabilities is a complex medical question that is beyond the competence of a layperson. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, for reasons outlined above, the preponderance of the evidence is against the claims of entitlement to service connection for a cervical spine disability and sleep apnea. As such, the benefit of the doubt doctrine is not for application, and service connection must be denied. 5. Entitlement to secondary service connection for a kidney disorder. Upon review of the evidence in the record, the Board finds that secondary service connection for a kidney disorder is not warranted because no current kidney disorder exists. In this regard, the July 2017 VA examiner found that the Veteran did not have a kidney disorder based on a thorough review of the Veteran’s medical history, physical examination, and the absence of diagnostic studies in the medical records indicating the existence of a kidney condition. The examiner highlighted the fact that the record revealed normal renal function tests and negative urinary microalbumin tests, and there was no evidence of diabetic nephropathy. Thus, the preponderance of the evidence is against the Veteran’s claim of secondary service connection for a kidney disorder. To the extent the Veteran asserts that he has a kidney disorder, the Board finds that this is a complex medical question that is beyond the competence of a layperson. See Jandreau, supra. Accordingly, as the first element of service connection is not met at any point during the appeal period, the claim fails on this basis alone. See Brammer, supra. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity in civil occupations. 38 U.S.C. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. If two disability ratings are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 6. Entitlement to a rating in excess of 10 percent for diabetes. The Veteran’s diabetes is evaluated under the criteria found at 38 C.F.R. § 4.119, DC 7913. A 10 percent evaluation is warranted for diabetes mellitus that is manageable by restricted diet only. A 20 percent evaluation is assigned for diabetes mellitus that requires insulin and restricted diet or oral hypoglycemic agent and a restricted diet. A 40 percent evaluation is appropriate for diabetes mellitus that requires insulin, restricted diet, and regulation of activities. A 60 percent evaluation is assigned for diabetes mellitus that requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least one or 2 hospitalizations per year or twice a month visits to a diabetes care provider, plus complications that would not be compensable if separately evaluated. A 100 percent evaluation is applicable for diabetes mellitus that requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least 3 hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, DC 7913. NOTE (1): Evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under DC 7913. By way of background, an August 2010 rating decision awarded service connection for diabetes and assigned a 10 percent rating, effective May 12, 2010. The current appeal period before the Board begins on March 14, 2014, the date VA received the Veteran’s claim for an increased rating, plus the one-year “look back” period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). Upon review of the totality of the record, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran’s diabetes at any point during the appeal period. At the August 2014 VA examination, the Veteran reported that he continued to control his diabetes with diet since his last VA examination in July 2010. The examiner noted that the Veteran’s diabetes was currently managed by restricted diet and that that he did not require regulation of activities. The examiner also noted that the Veteran visited his diabetic care provider for episodes of ketoacidosis and hypoglycemia less than 2 times per month but, he did not have any episodes of ketoacidosis or hypoglycemic reactions in the prior 12 months that required hospitalization, and did not have progressive unintentional weight loss or loss of strength attributable to diabetes. The examiner found complications of his diabetes included erectile dysfunction and diabetic peripheral neuropathy. Furthermore, VA treatment records reflect that the Veteran’s diabetes was diet controlled and well controlled throughout the appeal period. See e.g., April 2013, October 2013, April 2014, December 2014, and May 2016 VA treatment records. Thus, the preponderance of the evidence reflects that a rating in excess of 10 percent for diabetes is not warranted. In this regard, the record demonstrates that the Veteran’s diabetes has been managed by diet alone throughout the period on appeal. There is no indication of that the Veteran’s diabetes required the use of insulin or oral hypoglycemic agent at any point during the appeal period, and the Veteran does not assert otherwise. Therefore, a higher 20 percent rating is not warranted. 7. Entitlement to an initial rating in excess of 10 percent for left carpal tunnel syndrome. 8. Entitlement to an initial rating in excess of 10 percent for right carpal tunnel syndrome. The Veteran’s left and right carpal tunnel syndrome is rated pursuant to DC 8515, for paralysis of the median nerve. A 10 percent evaluation is assigned for mild incomplete paralysis (major or minor), moderate incomplete paralysis is rated 20 percent (minor) or 30 percent (major) disabling, and severe incomplete paralysis is rated 40 percent (minor) or 50 percent (major) disabling. Complete paralysis of the median nerve warrants a 60 percent (minor) or 70 percent (major) evaluation with the hand inclined to the ulnar side with the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, and the thumb in the plane of the hand (ape hand); incomplete and defective pronation of the hand with the absence of flexion of the index finger, feeble flexion of the middle finger, inability to make a fist, and index and middle fingers that remain extended; inability to flex the distal phalanx of the thumb with defective opposition and abduction of the thumb at right angles to the palm; weakened flexion of the wrist; and pain with trophic disturbances. 38 C.F.R. § 4.124a, DC 8515. In this case, the Veteran is right-handed. Therefore, his right upper extremity is considered major, and his left upper extremity is minor. In applying the schedular criteria for rating peripheral nerve disabilities, the term “incomplete paralysis” 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. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. 4.120. Under 38 C.F.R. 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. Words such as “moderate” and “mild” are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. Upon review of the totality of the record, the Board finds that ratings in excess of 10 percent are not warranted for the Veteran’s left and right carpal tunnel syndrome for the entire appeal period. The August 2014 diabetic sensory-motor peripheral neuropathy and peripheral nerves VA examination reports detail the Veteran’s reports of constant numbness and tingling pain in his hands bilaterally. Testing showed decreased reflexes in the bilateral triceps. Muscle strength, light touch, position sense, and cold sensation testing was normal for the upper extremities. There was no indication of muscle atrophy or trophic changes. Tinel’s tests were positive bilaterally, and Phalen’s tests were negative bilaterally. The examiner found that the left and right median nerves were affected and evaluated them as mild, but noted the Veteran exhibited mild symptoms of paresthesisas and numbness in his upper extremities. An October 2014 VA treatment record indicates the Veteran’s report of neuropathic pain in his upper extremities. The preponderance of the evidence shows that the Veteran’s bilateral carpal tunnel syndrome has resulted in mild paresthesisas, numbness, and pain. The August 2014 VA examination found decreased reflexes, which is more than wholly sensory symptoms. However, the examiner graded the Veteran’s overall did level as mild. This does not more nearly approximate moderate incomplete paralysis. Thus, ratings higher than 10 percent are not warranted for left and right carpal tunnel syndrome at any point during the appeal period. 9. Entitlement to an effective date prior to March 14, 2014 for the award of special monthly compensation based on loss of use of a creative organ. Generally, 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. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The effective date of an original award of direct service connection is the day following separation from active service or date entitlement arose if the claim is received within one year after separation from service; otherwise, it is the date of receipt of claim, or date entitlement arose, whichever is later. Id. Prior to March 24, 2015, any communication or action, indicating an intent to apply for one or more benefits under laws administered by VA, from a veteran or his representative, may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the veteran, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(a) (as in effect prior to March 24, 2015). The record shows that the Veteran first filed a claim for service connection for erectile dysfunction that was received by the RO on March 14, 2014. The record does not show any formal or informal claims for service connection for erectile dysfunction prior to this date, and the Veteran does not allege otherwise. A separate claim for special monthly compensation was not and has never been submitted. However, the Veteran previously filed a claim of service connection for diabetes in May 2010. As part of that claim, a VA examination was conducted in July 2010. It revealed a diagnosis of erectile dysfunction due to diabetes with symptoms present for 1 to 2 years prior. As shown more explicitly by an August 2014 VA examination, the diagnosis of erectile dysfunction is a complication of diabetes. Service connection for diabetes was granted in an August 2010 rating decision effective from May 12, 2010. The rating schedule for diabetes directs compensable complications of diabetes to be separately rated unless they are part of the criteria used to support a 100-percent evaluation or, if noncompensable, they are considered part of the diabetic process. See 38 C.F.R. § 4.119, DC 7913. Accordingly here, the claim of service connection for diabetes, when granted, reasonably raised the issue of compensation for erectile dysfunction. As that issue was not addressed, it remained pending until more explicitly claimed in March 2014. A January 2015 rating decision awarded service connection for erectile dysfunction as secondary to service-connected diabetes. In light of the grant of service connection for erectile dysfunction, the decision also awarded special monthly compensation based on the loss of use of a creative organ and assigned an effective date of March 14, 2014, the date the Veteran met the criteria for the benefit, which is also the date VA received the claim of entitlement to service connection for erectile dysfunction. However, as disability manifested earlier at the time when the initial claim of service connection for diabetes was granted, the issue of special monthly compensation based on the loss of use of a creative organ was also reasonably raised. Accordingly, special monthly compensation based on the loss of use of a creative organ is warranted from May 12, 2010. There is no legal basis to establish an earlier effective date for special monthly compensation based on loss of use of a creative organ as the May 12, 2010 date is the date on which service connection for diabetes became effective. There is no legal basis for an earlier date. REASONS FOR REMAND 1. Entitlement to service connection for hypertension is remanded. 2. Entitlement to secondary service connection for an eye disorder is remanded. Remand is warranted for the Veteran’s claim of entitlement to service connection for hypertension and an eye disorder as secondary to his service-connected diabetes. Regarding hypertension, the August 2014 VA examiner did not opine as to whether the Veteran’s hypertension was caused by his presumed herbicide agent exposure in Vietnam. Although the hypertension is not a disease associated with herbicide agent exposure under 38 C.F.R. § 3.309(e), the National Academy of Sciences (NAS) has concluded that there is “limited or suggestive evidence of an association” between herbicide agent exposure and hypertension. See 79 Fed. Reg. 20308, 20309-10 (Apr. 11, 2014). Additionally, the July 2017 VA examination reports are inadequate as the examiner did not provide opinions on secondary service connection based on aggravation as to the Veteran’s eye disorder. Furthermore, the July 2017 VA examiner opined that the Veteran’s hypertension was not secondary to his diabetes based on the fact that the Veteran’s history of hypertension was prior to the onset of his diabetes. However, to establish causation, there is no temporal requirement that the primary condition be service-connected, or even diagnosed, at the time the secondary condition is incurred. See Frost v. Shulkin, 29 Vet. App. 131 (2017). As such, addendum opinions are necessary. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 3. Entitlement to service connection for a bilateral upper extremity muscle disability is remanded. Remand is warranted as the August 2014 VA examination report is inadequate. Specifically, the examiner noted that the Veteran did not have a current diagnosis pertaining to a muscle condition and declined to provide an opinion as to the etiology of the claimed condition because no objective evidence of a muscle disability was identified by physical examination that day. However, the Veteran may be entitled to service connection for a disability that was present at any time during the appeal period, and Dr. Mora Quesada noted a diagnosis of myositis in the upper extremities in a March 2014 private treatment record. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Therefore, an addendum opinion should be obtained. 4. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran asserts his acquired psychiatric disorder had its onset in service following combat and traumatic experiences in Vietnam. See March 2014 private treatment record. The September 2014 and January 2015 VA examiners found that the Veteran did not have a diagnosed mental disorder and did not meet the criteria for a diagnosis of a mental disorder. However, both examiners did not give any rationale reconciling the mental disorder diagnoses reflected in the March 2014 private treatment record. Accordingly, an addendum opinion is necessary on remand. 5. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is remanded. 6. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity is remanded. A review of the record reveals that the Veteran’s peripheral neuropathy of the lower extremities may have worsened since his last VA examination in August 2014. In this regard, an October 2014 VA treatment record reflects significant and severe neuropathic symptoms in the Veteran’s lower extremities. However, it is unclear whether the neuropathic pain is solely due to his non-service-connected cervical spine disability or is associated with his service-connected diabetes. Therefore, the Board finds that a remand to provide the Veteran with a new VA examination is required. See 38 U.S.C. § 5103A(d); Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). 7. Entitlement to a TDIU is remanded. As the Veteran asserts that he is unemployable because of his service-connected disabilities, the Board finds that his claim for TDIU is inextricably intertwined with the above issues and must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Any outstanding VA and private treatment records should be secured. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any outstanding relevant private treatment records. 3. Then refer the claims file to a VA examiner for preparation of an addendum opinion as to the etiology of the Veteran’s hypertension. The entire claims file should be made available to the examiner. Following a review of the claims file, the examiner should opine as to whether it is as least as likely as not (50 percent or greater probability) that the Veteran’s hypertension: (a) had its onset in service or is otherwise related to service, to include as a result of conceded herbicide agent exposure therein; (b) is proximately due to service-connected diabetes; or (c) has been aggravated (worsened beyond natural progression) by his service-connected diabetes. In answering question (a), the examiner is asked to disregard whether the disorder is one for which a "presumption" is established and, instead, to answer whether the medical condition is a result of Agent Orange exposure even though it is not on the list of "presumptive" diseases. To this extent, please address the NAS findings of “limited or suggestive evidence of an association” between herbicide agent exposure and hypertension. Finally, even if hypertension preceded diabetes, please do not rely on this fact to support a lack of a causal relationship between the two unless a medical justification can be given for doing so. 4. Then obtain an addendum opinion addressing the etiology of the Veteran’s eye disorder. The entire claims file should be made available to the examiner. No additional examination is necessary, unless the examiner determines otherwise. Following a review of the claims file, the examiner should opine as to whether it is as least as likely as not (50 percent or greater probability) that the Veteran’s eye disorder, to include nuclear sclerosis, pinguecula, vitreous floaters, and glaucoma suspect: (a) is proximately due to service-connected diabetes; or (b) has been aggravated (worsened beyond natural progression) by his service-connected diabetes. 5. Then obtain an addendum opinion addressing the etiology of the Veteran’s bilateral upper extremity muscle disability. The entire claims file should be made available to the examiner. No additional examination is necessary, unless the examiner determines otherwise. Following a review of the claims file, the examiner should opine as to whether it is as least as likely as not (50 percent or greater probability) that the Veteran’s bilateral upper extremity muscle disability, to include myositis, had its onset in service or is otherwise related to service. 6. Then obtain an addendum opinion addressing the etiology of the Veteran’s psychiatric disorder. The entire claims file should be made available to the examiner. No additional examination is necessary, unless the examiner determines otherwise. Following a review of the claims file, the examiner is asked to address the following: (a) A diagnosis of posttraumatic stress disorder (PTSD) should be explicitly ruled in or excluded, and if diagnosed, the stressor(s) upon which such a diagnosis is based should be identified. If the Veteran does not meet the criteria for a diagnosis of PTSD, the examiner must reconcile this finding with the PTSD diagnosis in the March 2014 private treatment record. (b) Identify all psychiatric disorders, to include generalized anxiety disorder and major depressive disorder. If any of the diagnoses are not warranted, please reconcile these findings with the diagnoses of the same in the March 2014 private treatment record. (c) For each psychiatric disorder so diagnosed, please opine as to whether it is at least as likely as not (50 percent probability or greater) that such disorder had its onset in service or is otherwise related to the Veteran’s combat service. 7. Then schedule the Veteran for a VA examination to assess the current nature and severity of peripheral neuropathy of the left and right lower extremities associated with diabetes. The claims file should be made available to and be reviewed by the examiner, all necessary tests should be conducted, and all findings reported in detail. The examiner is asked to report the nature and severity of all signs and symptoms of the Veteran’s lower extremity peripheral neuropathy that are associated with diabetes, and fully assess and describe any impact that this disability has on his occupational functioning. C. BOSELY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S.S. Mahoney, Associate Counsel