Citation Nr: 18143624 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 17-46 716 DATE: October 19, 2018 ORDER Entitlement to service connection for a chronic back condition is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for diverticulitis is denied. Entitlement to service connection for gastrointestinal bleeding is denied. Entitlement to service connection for gastrointestinal polyps is denied. Entitlement to service connection for gastrointestinal hemorrhoids is denied. Entitlement to service connection for constipation is denied. Entitlement to service connection for an enlarged prostate is denied. Entitlement to service connection for urinary retention is denied. Entitlement to service connection for anemia is denied. Entitlement to service connection for high cholesterol is denied. Entitlement to a compensable evaluation for residuals of a right fifth finger injury with slight hypoalgesia is denied. REMANDED The claim of entitlement to service connection for sleep apnea is remanded. The claim of entitlement to service connection for a heart disorder, claimed as status post dual chamber pacemaker is remanded. The claim of entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and major depressive is remanded. The claim of entitlement to service connection for diabetes mellitus is remanded. The claim of entitlement to service connection for hyperthyroidism is remanded. The claim of entitlement to service connection for diabetic neuropathy of the bilateral upper extremities is remanded. The claim of entitlement to service connection for diabetic neuropathy of the bilateral lower extremities is remanded. The claim of entitlement to service connection for diabetic kidney disease, stage II is remanded. The claim of entitlement to service connection for peripheral vascular disease of the bilateral lower extremities is remanded. The claim of entitlement to service connection for peripheral vascular disease of the bilateral upper extremities is remanded. The claim of entitlement to service connection for erectile dysfunction is remanded. FINDINGS OF FACT 1. A back disorder did not have onset in service and is not otherwise related to service. 2. The Veteran’s hypertension did not have onset in service, is not otherwise related to service, and did not manifest to a compensable degree within one year of the Veteran’s separation from active duty service. 3. A disability manifested by an enlarged prostate did not have onset in service and is not otherwise related to service 4. The Veteran’s diverticulosis did not have onset in service and is not otherwise related to service, and is not caused or aggravated by a service-connected disability. 5. A disability manifested by gastrointestinal bleeding did not have onset in service and is not otherwise related to service, and is not caused or aggravated by a service-connected disability. 6. A disability manifested by gastrointestinal polyps did not have onset in service and is not otherwise related to service, and is not caused or aggravated by a service-connected disability. 7. Hemorrhoids did not have onset in service and is not otherwise related to service, and is not caused or aggravated by a service-connected disability. 8. A disability manifested by constipation did not have onset in service and is not otherwise related to service, and is not caused or aggravated by a service-connected disability. 9. A disability manifested by urinary retention did not have onset in service and is not otherwise related to service, and is not caused or aggravated by a service-connected disability. 10. The Veteran’s anemia did not have onset in service, is not otherwise related to service, and did not manifest to a compensable degree within one year of the Veteran’s separation from active duty service. 11. Although the Veteran is shown to have hyperlipidemia (including high cholesterol), this does not constitute a disability for purposes of an award of VA compensation. 12. There is no evidence of ankylosis or amputation of the Veteran’s service connected right little finger disorder. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disorder are not met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018). 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018). 3. The criteria for service connection for an enlarged prostate are not met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018). 4. The criteria for service connection for diverticulosis are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 5. The criteria for service connection for disability manifested by gastrointestinal bleeding are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 6. The criteria for service connection for disability manifested by gastrointestinal polyps are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 7. The criteria for service connection for hemorrhoids are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 8. The criteria for service connection for constipation are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 9. The criteria for service connection for urinary retention are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 10. The criteria for service connection for anemia have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018). 11. The criteria for entitlement to service connection for hyperlipidemia (high cholesterol) are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018). 12. The criteria for a compensable evaluation for residuals of right fifth finger injury with slight hypoalgesia have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.69, 4.71a, Diagnostic Codes 5157, 5227, 5230, 5309 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1950 to June 1952. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from May 2015, April 2016, and January 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In a September 2017 VA Form 9, the Veteran requested a Board hearing for all issues addressed herein other than the Veteran’s claim for service connection for a heart disorder, sleep apnea, and an increased rating for residuals of a right fifth finger injury. However, in a statement received in January 2018, the Veteran withdrew his request for a hearing. Another appeal of entitlement to a change in co-pay status is currently undergoing additional development. The Board will not address this matter in the instant decision. Duties to Notify and Assist For the issues decided herein, neither the Veteran nor his attorney has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Further, for the claims decided herein, the RO has not provided VA examination. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, and as discussed further below, though the evidence shows diagnoses of a low back disorder, hypertension, gastrointestinal disorders, to include constipation, erectile dysfunction, an enlarged prostate, urinary retention, and anemia, there is no indication that any of these disorders are related to any in-service event, injury, or disease, or with another service-connected disability. Even under the low threshold set by McLendon, the Board finds that VA has no duty to provide examinations for the Veteran’s claims. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2018). In addition, service connection for certain chronic diseases, including arthritis, hypertension, anemia, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2018); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive 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. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309 (2018); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2018); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 1. Entitlement to service connection for a chronic back condition The Veteran has not advanced any specific contention regarding his claimed back disorder other than his general application for service connection. After a thorough review of the record, the Board finds that service connection is not warranted. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). VA treatment records show that the Veteran underwent a decompression procedure for lumbar stenosis in August 2014. In November 2009, the Veteran presented to VA with complaints of sciatic pain. Diagnostic testing revealed degenerative changes of the spine. As such, a present disability is shown. Second, the Board finds that there was not an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). Notably, the Veteran does not assert a specific injury during his active duty service. His statements provide little insight into why he believes his low back condition should be service-connected. The Veteran’s service treatment records do not show any injury or disease of the spine. As such, an in-service injury, event, or disease is not shown. Third, the Board finds that the evidence of record does not support a finding that the Veteran’s diagnosed spine disorder is related to active service. Absent a showing of an in-service event, injury, or disease of the spine, establishment of a nexus is impossible. However, even assuming the Veteran claims his low back disorder is related to wear and tear sustained to his spine during service, the evidence weighs against his claim. First, the evidence does not show that the Veteran’s spine disorder manifested until recently, over 50 years after his military service. The passage of many years between discharge from active service and the medical documentation of a claimed disability may be considered as evidence against a claim of entitlement to service connection. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting that the trier of fact should consider evidence of a prolonged period without medical complaint along with all of the relevant facts and available evidence). In addition to the passage of time between the Veteran’s active service and his low back complaints, there is no competent evidence or opinion suggesting that there exists a medical nexus between the Veteran’s current low back disorder and his active service. Therefore, entitlement to service connection is not warranted on a direct basis. In addition, the Veteran’s low back disorder manifested well after one year after the Veteran separated from active service. As such, service connection on a presumptive basis is not warranted under 38 C.F.R. §§ 3.307 (a), 3.309(a). To the extent that the Veteran asserts his low back disorder was related to service, the Board finds that his statements are not competent. Although it is error to categorically reject a lay person as competent to provide a nexus opinion, not all questions of nexus are subject to non-expert opinion. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Whether a layperson is competent to provide a nexus opinion depends on the facts of the particular case. “Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay witnesses are competent to report that which they have observed with their own senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). But here, the specific etiology of lumbar spine arthritis is not capable of lay observation as it is a complex internal process and is distinguishable from ringing in the ears, a broken leg, or varicose veins. See Jandreau, 492 F.3d at 1377; Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002). Accordingly, the Board does not assign any probative weight to these statements. In short, service connection is not warranted on direct or presumptive bases because there is no competent evidence of record to support the Veteran’s claim. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for hypertension As with the Veteran’s back, the Board notes that the Veteran has not advanced any specific theory of entitlement for his claimed hypertension. A VA treatment record shows a series of blood pressure readings taken on July 1986 showing elevated blood pressure readings. However, no diagnosis of hypertension is of record until the 2000s. In any event, a present disability is shown. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). However, the evidence does not show that hypertension had onset in service or is otherwise related to service. The Veteran’s STRs do not show any hypertension. In addition, there is no objective opinion evidence of record linking the Veteran’s hypertension to his military service. The only evidence purporting to link the Veteran’s hypertension to his military service are his statements. However, the etiology of hypertension is not capable of lay observation as it is a complex internal process and is distinguishable from observable conditions. As such, the Veteran’s lay statements asserting hypertension is related to service are not competent lay statements. In summary, the evidence is against a finding that service connection is warranted on a direct basis. In addition, the evidence does not show hypertension having onset within one year of the Veteran’s military service. As such, service connection is not warranted on a presumptive basis. 38 C.F.R. §§ 3.307 (a), 3.309(a). In short, service connection is not warranted on direct or presumptive bases. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for an enlarged prostate As with his other claims, the Veteran has not advanced any specific argument in support of his claim for service connection for a disability manifested by an enlarged prostate other than submitting a claim of entitlement to service connection for an enlarged prostate. After a review of the record, the Board finds that service connection is not warranted. VA treatment records document a diagnosis of benign prostatic hyperplasia. See e.g. records of VA treatment from August 2014. However, the evidence does not show that benign prostatic hyperplasia had onset in service or is otherwise related to service. The Veteran’s STRs do not show any symptoms related to an enlarged prostate. In addition, there is no objective opinion evidence of record linking the Veteran’s benign prostatic hyperplasia, and any corresponding disabling effects, to his military service. The only evidence purporting to link the Veteran’s disorder to his military service are his statements. However, the etiology of benign prostatic hyperplasia is not capable of lay observation as it is a complex internal process and is distinguishable from observable conditions. As such, the Veteran’s lay statements asserting his condition is related to service are not competent lay statements. In summary, the evidence is against a finding that service connection is warranted on a direct basis. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for diverticulosis, hemorrhoids, gastrointestinal bleeding, gastrointestinal polyps, constipation, urinary retention, and anemia The Board finds that service connection for the Veteran’s claimed diverticulosis, hemorrhoids, gastrointestinal bleeding, gastrointestinal polyps, and constipation is not warranted. As with his other claims, the Veteran has not advanced specific contentions for these conditions. However, as explained further below, these claims should be addressed in direct and secondary theories of entitlement. VA treatment records show that the Veteran underwent a Barium enema in January 1987. The test revealed minimal diverticulosis of the sigmoid colon. Private treatment records from March 2007 show that the Veteran underwent a colonoscopy showing a few small-mouthed diverticular in the sigmoid colon and internal, non-bleeding, small hemorrhoids. The examination was otherwise without abnormality. December 1987 VA treatment records show the Veteran seeking for rectal bleeding that had intermittently affected him for the previous five years. The Veteran indicated that he had undergone hemorrhoid surgery in the past. A provisional diagnosis of external hemorrhoids was rendered. A follow-up examination conducted in January 1987 confirmed the presence of minimal external hemorrhoids. In a letter received in September 2014, the Veteran’s treating physician indicated that the Veteran had recently been hospitalized after complications of a lumbar decompression surgery. The Veteran had been admitted with urinary retention and gastrointestinal bleeding. Records of this visit indicate that the Veteran presented to the emergency department with complaints of lower gastrointestinal bleeding. He was noted to have a history of constipation. A colonoscopy showed polyps, hemorrhoids, and diverticulosis. The Veteran was also suffering from urinary retention and anemia. VA treatment records from June 2012 note that the Veteran had recently been evaluated by his primary care doctor for anemia, and VA treatment records document that the Veteran had suffered from anemia chronically. The Board finds that a present disability is shown. Regarding hemorrhoids and diverticulosis, the evidence shows the Veteran has a history of these conditions extending back to the 1987. In 1987, the Veteran was noted to have a previous history or hemorrhoid surgery. In addition, the Veteran is documented as having urinary retention, constipation, gastrointestinal bleeding, and polyps on colonoscopy in 2014 after seeking treatment as a complication from an August 2014 lumbar decompression surgery. Those records also document anemia. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). However, the evidence does not show that diverticulosis, hemorrhoids, gastrointestinal bleeding, gastrointestinal polyps, constipation, urinary retention, and anemia had onset in service or are otherwise related to service. The Veteran’s service treatment records do not show any of these conditions. In addition, there is no objective opinion evidence of record linking the Veteran’s conditions to his military service. The only evidence purporting to link the Veteran’s conditions to his service are Veteran’s claims and appeal documents. However, the etiology of diverticulosis, hemorrhoids, gastrointestinal bleeding, gastrointestinal polyps, constipation, urinary retention, and anemia is not capable of lay observation as these disorders are complex internal process and are distinguishable from observable conditions. As such, the Veteran’s lay statements asserting diverticulosis, hemorrhoids, gastrointestinal bleeding, gastrointestinal polyps, constipation, urinary retention, anemia are related to service are not competent lay statements. In summary, the evidence is against a finding that service connection is warranted on a direct basis for diverticulosis, hemorrhoids, gastrointestinal bleeding, gastrointestinal polyps, constipation, urinary retention, and anemia. To the extent a secondary theory of entitlement is raised because the Veteran suffered from gastrointestinal bleeding, polyps, anemia, and urinary retention after his lumbar decompression surgery, the Board finds that service connection is not warranted. Service connection is not warranted on this basis because service connection is not in effect for the Veteran’s low back disorder. A VA treatment records from August 2014 also noted that the Veteran’s urinary retention was likely induced by underlying benign prostatic hyperplasia in addition to narcotics taken to treat the Veteran’s back recovery after the August 2014 surgery. However, service connection for a prostate disorder is also denied herein. Thus, service connection on a secondary basis for urinary retention as related to a prostate disorder is not warranted. Regarding anemia, service connection is also not warranted on a presumptive basis because there is nothing to suggest that this disability manifested to a compensable degree within one year of the Veteran’s separation from active duty. 38 C.F.R. §§ 3.307 (a), 3.309(a). In short, service connection is not warranted on a direct basis or secondary basis for the Veteran’s claims of entitlement to service connection for diverticulosis, hemorrhoids, gastrointestinal bleeding, gastrointestinal polyps, constipation, urinary retention, and anemia. Service connection is also not warranted on a presumptive basis for anemia. In reaching this decision the Board has considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to service connection for high cholesterol The Board finds that service connection for high cholesterol, or hyperlipidemia, is not warranted. The evidence shows that the Veteran has been found to have high cholesterol. High cholesterol is also referred to as hypercholesterolemia or hyperlipidemia. However, hypercholesterolemia is simply defined as an “excess of cholesterol in the blood.” Dorland’s Illustrated Medical Dictionary 792 (28th ed. 1994) and hyperlipidemia is “a general term for elevated concentrations of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia, etc.” Id. at 795. Hyperlipidemia and elevated cholesterol are considered to be laboratory findings and therefore are not disabilities in and of themselves for which VA compensation benefits are payable. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (Diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule.). The term “disability” as used for VA purposes refers to impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In this regard, the evidence of record does not suggest the Veteran’s elevated cholesterol causes any impairment of earning capacity. In the absence of proof of current disability there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, the Veteran’s claim for service connection for high cholesterol must also be denied. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2018). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2018). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2018). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. As noted above, the Veteran is in receipt of a noncompensable rating for his right little finger disorder. The rating is assigned pursuant to Diagnostic Code 5230. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45 (2017). VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). The possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, less or more movement than normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Mitchell, 25 Vet. App. 32; 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2018). Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran’s little finger disorder is rated noncompensably under Diagnostic Code 5230. Per Diagnostic Code 5230, any limitation of motion of the little finger is to be noncompensably rated. See 38 C.F.R. § 4.71a, Diagnostic Code 5230. Under Diagnostic Code 5227, favorable or unfavorable ankylosis of the little finger, is to be rated noncompensable. The Board will also consider the rating criteria for injury to the intrinsic muscles of the hand. Specifically, such disability may be rated under the diagnostic code for muscle group VII or IX that control grasping and delicate manipulative movements. 38 C.F.R. § 4.73, Diagnostic Code 5307, 5309. Generally, muscle group damage is categorized as slight, moderate, moderately severe and/or severe and evaluated accordingly under 38 C.F.R. § 4.56 (2018). With respect to Diagnostic Code 5309; however, different criteria apply. As indicated in that diagnostic code, Muscle Group IX consists of the intrinsic muscles of hand, the thenar eminence, short flexor, opponens, abductor and adductor of the thumb, the hypothenar eminence, and the short flexor, opponens and abductor of the little finger. The forearm muscles act in strong grasping movements and are supplemented by the intrinsic muscles in delicate manipulative movements. The hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc. Thus, injury to muscle group IX should be rated on limitation of motion, with a minimum 10 percent assigned. 38 C.F.R. § 4.73, Diagnostic Code 5309, Note (2018). The Veteran presented for a hand and finger VA examination in December 2016. The examiner reviewed the Veteran’s electronic folder and his medical records. The injury listed was an injury to the right pinky finger. The Veteran reported that his symptoms had remained the same. Basically, the finger was tender when bumped. He also reported that he had some difficulty gripping items in the right hand. On clinical examination, range of motion of the little finger was normal. There was no evidence of pain with use of the hand. There was no objective evidence of localized tenderness or pain on palpation. Further, the Veteran was able to perform repetitive use testing with at least three repetitions with no additional functional loss or limitation of motion. Essentially, any functional impairment was described as some difficulty with gripping items in the right hand. However, the examination showed normal grip strength and no muscle atrophy. In an October 2017 correspondence, the Veteran disputed the VA examiner’s findings, noting that his right little finger had been painful ever since his in-service injury to that digit. The pain was the reason that he had difficulty gripping objects with his right hand. The evidence during the appeal period is otherwise silent regarding the Veteran’s service-connected right little finger disorder. As noted above, the Veteran is currently rated as noncompensable under Diagnostic Code 5230. This Diagnostic Code provides that any range of motion loss is noncompensable. Thus, an increased rating is not warranted under DC 5230. In Southall-Norman, the Court held that 38 C.F.R. § 4.59 applies to musculoskeletal disabilities involving actually painful, unstable or malaligned joints regardless of whether the diagnostic code under which the disability is evaluated is predicated on range of motion testing. See Southall-Norman, 28 Vet. App. at 354. However, the Court has cautioned that 38 C.F.R. § 4.59 does not provide an independent basis for a compensable rating. See Sowers v. McDonald, 27 Vet. App. 472, 482-81 (2015). Instead, the regulation must be read in conjunction with the applicable diagnostic code. Id. at 479. In Sowers, the Court rejected the appellant’s argument that, under § 4.59, he was entitled to a compensable rating for painful motion of the right ring finger. Id. at 477. The Court rejected his argument because Diagnostic Code 5230 (limitation of motion of the ring or little finger) provides only a noncompensable rating. As the Court explained, “Reading § 4.59 in conjunction with DC 5230, [the appellant] is not entitled to a compensable rating under this DC. Section 4.59 intends to recognize actually painful joints and provide at least the minimum compensable rating for the joint. There is no minimum compensable rating under DC 5230, that is, any level of disability warrants a 0% rating. DC 5230’s specific finding that there is no impairment in earning capacity from any limitation of motion of the ring finger trumps the general intent of § 4.59 to compensate painful motion with at least the minimum compensable rating.” Id. at 480 (emphasis in original). Thus, the Board finds that the Court’s holding in Southall-Norman does entitle the Veteran to a compensable rating under 38 C.F.R. § 4.59. Further, a compensable rating under DC 5309 is not warranted. Under that code, injury to muscle group IX should be rated on limitation of motion, with a minimum 10 percent assigned. However, objective testing in the December 2016 VA examination did not yield evidence of limitation of motion. The only symptoms identified were tenderness when the finger is bumped and difficulty gripping per the Veteran’s reports. A compensable rating is not warranted with these symptoms under DC 5309 because there is no objective evidence of limited motion or other symptoms that would approximate limited motion. The Board has further considered whether an increased rating is warranted for the Veteran’s right ring finger disability based on functional loss due to pain, weakness, excess fatigability, incoordination, and flare-ups. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). If, however, the Veteran is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider the applicability of the above provisions. Johnston v. Brown, 10 Vet. App. 80 (1997). Additionally, the Veteran is not entitled to a disability rating under Diagnostic Code 5003 as there has not been a showing by x-ray evidence of degenerative changes of the right hand. There has also been no showing of ankylosis. Moreover, even if Diagnostic Code 5227 did apply, a compensable rating is not available for unfavorable or favorable ankylosis of the ring or little finger of the major or minor hand. The Veteran’s right little finger is intact and thus, a compensable rating would not be warranted under Diagnostic Code 5156 for amputation. The Board has reviewed the relevant diagnostic criteria and finds that the preponderance of evidence is against a finding that a compensable rating is warranted for the Veteran’s right little finger disorder. REASONS FOR REMAND Before discussing specific reasons for remand, the Board again notes that VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d) (2012); 38 C.F.R. § 3.159(c)(4) (2018). Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). 1. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and major depressive disorder Initially, the Board notes that the record reflects that the Veteran has pursued separate service connection appeals for PTSD and depressive disorder. But, as both claims involve a psychiatric disability, the Board finds it appropriate to consolidate the claims into a single claim as entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depressive disorder. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Remand is required to provide an examination for the Veteran’s claim. In a statement received in April 2016, the Veteran contended that he had PTSD as a result of two incidents in service. In one, he had to bury an artillery round after it had misfired. In the other, the Veteran lost his hearing temporarily while working on an artillery team. As a result, he was unable to hear his officer. His officer reportedly became angry with the Veteran and removed him from his duty station. The Veteran reported that this incident had bothered him constantly and that he was unable to sleep at night as a result. He also described being very depressed and having bad dreams. In a May 2016 statement, the Veteran clarified that the incidents described in his April 2014 correspondence occurred in Philadelphia and Reading, Pennsylvania, while guarding these cities against air attack. He was assigned to the 102nd Anti-Aircraft Artillery, B Battery, attached the 1st Army. In a December 2016 memorandum, a formal finding on the lack of information required to verify stressors in a PTSD claim was made. The memorandum documented a finding that the information provided by the Veteran did not meet the requirements needed to corroborate the stressful events described in his statements. The information provided was insufficient to allow for meaningful research. With his VA Form 9 that was received in October 2017, the Veteran submitted a statement describing how his military experience caused PTSD. He mentioned that the reality of firing artillery and having to learn hand-to-hand combat was extremely frightening. Further, he had joined the National Guard to protect the State of New York and not die in a foreign country. However, the selection process for Korea was randomized and produced fear and eventual terror that he would be selected to serve abroad. He indicated that it was well documented that psychiatric care for Korean and Vietnam War veterans was lacking until recently and that he had been fearful of reprisal by the thought of seeking psychiatric treatment. He then described a series of psychiatric symptoms he had experienced since his military service. He also indicated that he was scheduled for his first evaluation session with a VA psychiatric evaluator in October 2017. As the Veteran indicated, he received an initial evaluation with VA in October 2017. The Veteran presented with complaints of sleep disturbances since 1952. He also discussed having a “PTSD thing for years.” He also reported a history of depression and anxiety throughout his life, indicating that it had not gotten better since his service in 1952. He reported that he had experienced suicidal ideation but that he had no plan. Diagnostic impressions included anxiety disorder, depressive disorder, and trauma and stressor-related disorder. In short, there are present psychiatric diagnoses, complaints of in-service events, and an indication that the diagnosed conditions may be associated with service. Considering the low threshold set in McLendon, the Board finds that an examination is warranted to develop the Veteran’s claim. 2. Entitlement to service connection for sleep apnea The Board finds that remand is necessary to provide a VA examination for the Veteran’s claim of entitlement to service connection for sleep apnea. Here, an October 2015 VA note documents a diagnosis of severe sleep apnea. Further, with his October 2017 VA Form 9, the Veteran provided a statement indicating that his wife had personally witnessed sleep deprivation and severe snoring since they had been married in 1957. This raises a direct theory of entitlement and suggests that symptoms commonly attributable to sleep apnea dated back to a time closer to the Veteran’s service. In light of the low threshold set in McLendon, the Board finds that there is an indication that presently diagnosed sleep apnea may be associated with service. Further, to the extent the Veteran claims that sleep apnea is secondarily related to his claimed psychiatric disorder, the Veteran’s claim is inextricably intertwined with the remanded psychiatric disorder claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (noting that 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). 3. Entitlement to service connection for a heart disorder, claimed as status post dual chamber pacemaker Next, the Veteran asserts that his sleep apnea is a main contributing factor to his heart disorder, requiring a dual-chamber pacemaker. To the extent the Veteran alleges his claimed heart condition is secondarily related to his claimed sleep apnea, the heart claim is inextricably intertwined with his claimed sleep apnea. Thus, remand is appropriate pending a final adjudication of the sleep apnea claim. 4. Entitlement to service connection for diabetes mellitus, peripheral vascular disease of the bilateral lower extremities, peripheral vascular disease of the bilateral upper extremities, diabetic kidney disease, hyperthyroidism, diabetic neuropathy of the bilateral upper extremities, diabetic neuropathy of the bilateral lower extremities, and erectile dysfunction. Beginning with the Veteran’s claim diabetes mellitus, type II, the Veteran has not advanced any specific arguments regarding his claim other than generally asserting that the condition should be service-connected. However, the record has raised a secondary theory of entitlement. Specifically, an October 2015 VA treatment note shows how the Veteran was informed how glucose levels can be affected by sleep apnea. To the extent the Veteran claims that sleep apnea is secondarily related to his claimed psychiatric disorder, the Veteran’s claim is inextricably intertwined with the remanded psychiatric disorder claim. See Harris v. Derwinski, 1 Vet. App. 180. Similarly, the record suggests that diagnoses of peripheral vascular disease of the bilateral upper and lower extremities, diabetic kidney disease, hyperthyroidism, diabetic neuropathy of the bilateral upper and lower extremities, and erectile dysfunction are secondarily related to the Veteran’s claimed diabetes mellitus on either causal or aggravation bases. As such, the claims are inextricably intertwined and may not be adjudicated until development undertaken for the primary claims is completed. See Harris, supra. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 2. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the nature and etiology of his claimed psychiatric disorders. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must determine whether the Veteran has a current diagnosed disability to include PTSD or depressive disorder that meets the DSM criteria. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any diagnosed disorder had onset in, or is otherwise related to, active military service. The examiner must specifically address the Veteran’s assertions of in-service stressors, including burying a misfired artillery round and being removed from his duty station by an angry officer. The examiner must also specifically address the Veteran’s statements that he suffered from psychiatric symptoms that had existed since 1952, when he separated from active duty. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his sleep apnea. The entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. (Continued on the next page)   The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that sleep apnea had onset in or is otherwise related to the Veteran’s military service. The examiner must specifically address the Veteran’s statements in his October 2017 VA Form 9 indicating that his wife had witnessed sleep deprivation and excessive snoring dating back to when they were married in 1957. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Steve Ginski, Associate Counsel