Citation Nr: 18145741 Decision Date: 10/30/18 Archive Date: 10/29/18 DOCKET NO. 16-11 807 DATE: October 30, 2018 ORDER Service connection for shin splint, left leg, is denied. Service connection for shin splint, right leg, is denied. Service connection for gout, left foot, is denied Service connection for gout, left ankle, is denied. Service connection for gout, left knee, is denied. Service connection for gout, right knee, is denied. Service connection for hearing loss, right ear, is denied. Service connection for a sleep condition, to include sleep apnea, is denied. Service connection for a lung condition, to include asthma, is denied. An initial evaluation of more than 50 percent for chondromalacia patella, right knee, is denied. An initial evaluation of more than 20 percent for right ankle strain is denied. An initial compensable evaluation for subluxation of fifth metatarsophalangeal (MTP) joint, right foot, is denied. An initial evaluation of more than 50 percent for patellofemoral pain syndrome, left knee, is denied. An increased evaluation of more than 20 percent for residuals of injury, left ankle, is denied. An initial compensable evaluation for left foot erosion is denied. An initial evaluation of more than 10 percent for bilateral tinnitus is denied. An initial compensable evaluation for hearing loss, left ear, is denied. An effective date prior to July 3, 2012, for the grant of service connection for chondromalacia patella, right knee, is denied. An effective date prior to July 3, 2012, for the grant of service connection for right ankle strain, is denied. An effective date prior to July 3, 2012, for the grant of service connection for bilateral tinnitus, is denied. An effective date prior to July 3, 2012, for the grant of service connection for subluxation of fifth metatarsophalangeal joint, right foot, is denied. An effective date prior to July 3, 2012, for the grant of service connection for left foot erosion is denied. An effective date prior to July 3, 2012, for the grant of service connection for hearing loss, left ear, is denied. An effective date prior to July 3, 2012, for the grant of service connection for patellofemoral pain syndrome, left knee, is denied. An effective date prior to July 3, 2012, for the increased evaluation for residuals of injury, left ankle, is denied. REMANDED Entitlement to service connection for acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) or major depressive disorder, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s bilateral shin splints began during active service or are otherwise related to an in-service injury, event, or disease, or that they were proximately due to or aggravated beyond their natural progression by his service-connected leg disabilities. 2. The preponderance of the evidence is against finding that the Veteran’s gout in the left foot began during active service, or is otherwise related to an in-service injury, event, or disease. 3. The preponderance of the evidence is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of gout in the left ankle, left knee, or right knee. 4. The preponderance of the evidence is against finding that the Veteran has, or has had at any time during the appeal, a current right ear hearing loss disability. 5. The preponderance of the evidence is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of sleep apnea or other sleep condition as separate from symptoms of a mental health disability. 6. The Veteran’s only diagnosed lung or respiratory condition, currently or at any point during the appeal period, is asthma or allergies with breathing difficulties; and the preponderance of the evidence is against finding that the current disability began during active service, or is otherwise related to an in-service injury, event, or disease, to include any exposure to asbestos, chemicals, or contaminated water. 7. The Veteran is in receipt of a combined rating of 60 percent for disabilities of the right leg to the knee level, including the right knee, ankle, and foot, which is the rating that would be applied if the leg were amputated at the knee level. 8. The Veteran is in receipt of a combined rating of 60 percent for disabilities of the left leg to the knee level, including the left knee, ankle, and foot, which is the rating that would be applied if the leg were amputated at the knee level. 9. The Veteran has been assigned the maximum schedular rating for tinnitus. 10. Throughout the appeal period, the Veteran has had no more than Level I hearing loss in the left ear and no service-connected right ear hearing loss. 11. The Veteran’s first claim for service connection for right knee, right ankle, right foot, left foot, tinnitus, and hearing loss disabilities was received July 3, 2012. 12. The Veteran’s first claim for service connection for a left knee disability was received in October 1991, and a September 1996 denial became final; his next claim for service connection for left knee disability was received July 3, 2012. 13. The Veteran’s claim for an increased rating for the left ankle was received July 3, 2012, after the initial service connection award became final, and an increase in disability level was not factually ascertainable within one year prior to that claim. CONCLUSIONS OF LAW 1. The criteria for service connection for shin splint, left leg, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.310 (2018). 2. The criteria for service connection for shin splint, right leg, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.310 (2018). 3. The criteria for service connection for gout, left foot, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 4. The criteria for service connection for gout, left ankle, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 5. The criteria for service connection for gout, left knee, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 6. The criteria for service connection for gout, right knee, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 7. The criteria for service connection for hearing loss, right ear, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.385 (2018). 8. The criteria for service connection for a sleep condition, to include sleep apnea, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 9. The criteria for service connection for a lung condition, to include asthma, are not met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309(f) (2018). 10. The criteria for an initial evaluation of more than 50 percent for chondromalacia patella, right knee, are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Codes 5003-5261 & 5154 (2018). 11. The criteria for an initial evaluation of more than 20 percent for right ankle strain, are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Codes 5271 & 5154 (2018). 12. The criteria for an initial compensable evaluation for subluxation of fifth MTP joint, right foot, are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Codes 5277, 5284, & 5154 (2018). 13. The criteria for an initial evaluation of more than 50 percent for patellofemoral pain syndrome, left knee, are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Codes 5003-5261 & 5154 (2018). 14. The criteria for an increased evaluation of more than 20 percent for residuals of injury, left ankle, are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Codes 5271 & 5154 (2018). 15. The criteria for an initial compensable evaluation for left foot erosion are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Codes 5277, 5284, & 5154 (2018). 16. The criteria for an initial evaluation of more than 10 percent for bilateral tinnitus, are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.87, Diagnostic Code 6260 (2018). 17. The criteria for an initial compensable evaluation for hearing loss, left ear, are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, Diagnostic Code 6100 (2018). 18. The criteria for an effective date prior to July 3, 2012, for the grant of service connection for chondromalacia patella, right knee, are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.155, 3.400 (2014 & 2018). 19. The criteria for an effective date prior to July 3, 2012, for the grant of service connection for right ankle strain are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.155, 3.400 (2014 & 2018). 20. The criteria for an effective date prior to July 3, 2012, for the grant of service connection for bilateral tinnitus are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.155, 3.400 (2014 & 2018). 21. The criteria for an effective date prior to July 3, 2012, for the grant of service connection for subluxation of fifth MTP joint, right foot, are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.155, 3.400 (2014 & 2018). 22. The criteria for an effective date prior to July 3, 2012, for the grant of service connection for left foot erosion are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.155, 3.400 (2014 & 2018). 23. The criteria for an effective date prior to July 3, 2012, for the grant of service connection for hearing loss, left ear, are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.155, 3.400 (2014 & 2018). 24. The criteria for an effective date prior to July 3, 2012, for the grant of service connection for patellofemoral pain syndrome, left knee, are not met. 38 U.S.C. §§ 5104, 5110, 7105 (2012); 38 C.F.R. §§ 3.104, 3.155, 3.158, 3.160, 3.400 (2014 & 2018). 25. The criteria for an effective date prior to July 3, 2012, for the increased evaluation for residuals of injury, left ankle, are not met. 38 U.S.C. §§ 5110, 5104, 7105 (2012); 38 C.F.R. §§ 3.104, 3.155, 3.158, 3.160, 3.400 (2014 & 2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service in the U.S. Marines from December 1988 through May 1991, when he was discharged after due to unfitness based on left ankle and knee disabilities. He submitted the current claim in July 2012, and he perfected an appeal to the Board through a March 2016 VA Form 9 for all 26 issues addressed in the statement of the case. Although the Veteran’s attorney submitted arguments only concerning a mental health claim and TDIU, the remaining issues on appeal have not been withdrawn and are before the Board. Concerning the issues on appeal, the Veteran identified his November 2012 mental health claim as for PTSD; however, VA and private medical records reflect diagnoses of PTSD, depression or major depressive disorder, anxiety, severe insomnia noted as related to his mental health conditions, or major depressive disorder rule out PTSD. See, e.g., VA records in October 2012, April 2014, and May 2015; private evaluation received in September 2016 (dated in September 2015). Therefore, this claim has been recharacterized as PTSD or other acquired psychiatric disorder, to encompass all diagnoses encompassing the Veteran’s mental health symptoms. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). Additionally, although the agency of original jurisdiction (AOJ) has not yet adjudicate the issue of TDIU, the Board has jurisdiction over TDIU claims that are raised in conjunction with underlying rating claims on appeal. A request for TDIU, whether expressly raised by an appellant or reasonably raised by the record, is not generally a separate claim for benefits but, rather, is an alternative to a schedular rating for a disability. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The internal rating code sheet associated with the October 2013 rating decision leading to this appeal notes that the issue of TDIU was inferred because the Veteran met the schedular criteria for TDIU with a combined rating of 90 percent and was currently unemployed. The plan was to develop the issue of TDIU as appropriate and adjudicate it; however, there is nothing in the claims file indicating that notice, development, or adjudication was completed for the TDIU issue. In September 2016, the Veteran’s attorney submitted arguments and evidence to show unemployability for VA purposes since 2012 due to pain and impairment from the service-connected disabilities and the claimed mental health disability. Thus, a TDIU is under the Board’s jurisdiction as part of the underlying rating claims. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. Secondary service connection will be granted if the evidence demonstrates that a current disability is proximately due to or the result of, or aggravated beyond its natural progression, by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310. In adjudicating such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. & 2. Entitlement to service connection for shin splints, left and right legs. In his July 2012 claim, the Veteran identified claims for “left leg injury” and “right leg secondary [to] left leg injury,” as well as “stress fractures [in] both knees,” and in the remarks noted “bilateral ankle/foot condition.” In an April 2013 statement, the Veteran described pain and other symptoms involving his feet, ankles, and knees, but did not specifically mention shin splints. In the October 2013 rating decision, the AOJ awarded service connection and initial ratings for bilateral knee, foot, and ankle disabilities, which are discussed in the increased rating section below, but separately denied service connection for bilateral shin splints. The Veteran identified these issues as being appealed in his May 2014 notice of disagreement, but he did not specify a reason, stating only that he wished to appeal all issues and wanted the maximum benefits available. The Veteran has not made subsequent assertions concerning shin splints, and his attorney also did not make any arguments concerning shin splints. There is no evidence concerning shin splints in service treatment records or VA treatment records. During a July 2013 VA examination, the Veteran reported daily leg pain involving his knees, ankles, and feet. The examiner diagnosed shin splints, also known as medical tibial stress syndrome, based on reports of pain and evidence of tenderness to palpation in the front of both shins on examination, with normal X-rays of the bilateral tibia/fibula. The examiner gave negative opinions for direct and secondary service connection concerning the bilateral shin splints. There is no contrary medical or lay evidence concerning the timing or etiology of the Veteran’s shin splints, and no argument that another opinion is needed. The preponderance of the evidence weighs against finding that the current bilateral shin splints are directly related to an in-service injury, event, or disease, or were secondarily caused or aggravated beyond the natural progression by his service-connected disabilities. There is no doubt to be resolved in the Veteran’s favor, and the claims must be denied. 38 C.F.R. §§ 3.102, 3.303(a), (d), 3.310(a). 3. , 4., 5., & 6. Entitlement to service connection for gout, left foot, left ankle, left knee, and right knee. In an April 2013 statement, the Veteran asserted that he had problems with his left ankle and knees in service and since that time, and that he now has gout in the left foot, left ankle, and knees. His attorney did not make arguments concerning gout. The first element of service connection is a current disability. VA treatment records establish a current diagnosis of gout in the left foot, specifically the big toe, for which he was prescribed allopurinol. See, e.g., records in April 2011, September 2012 (noting gout in the right toe per prior VA providers, but that appears to be a typographical error based on other records, and the fact that the Veteran has not claimed gout in the right toe), April 2015, April 2016, May 2016. However, the Veteran has not had a diagnosis of gout in the left ankle or either knee at any time during the pendency of the claim or recent in time to the filing of the claim. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). VA treatment records only mention gout in the left foot or toe, and when the Veteran complained that he believed this gout had spread to the ankle or other knee, he was not diagnosed with gout in those areas. A July 2011 phone message reflects that the Veteran reported his left foot gout pain had progressed to his knee. However, an August 2011 primary care follow-up record noted right knee pain and swelling with some warmth for three weeks, with difficulty walking and reduced swelling but continued pain at this point. The provider noted the Veteran’s prior knee injury and diagnosed right knee pain, but not gout. Similarly, an April 2016 record notes that the Veteran believed his gout in the left foot was now moving to his ankle. However, follow-up records for an extended episode of left foot problems in April and May 2016 continue to note gout and an infection only in the left toe or foot, with increased redness at the base of the big toe, edema, and warmth to the first digit, radiating to the top of foot and under the foot. Although the Veteran believes he has gout in the left ankle, left knee, and right knee, he is not competent to provide a diagnosis. This issue is medically complex and requires medical knowledge of the interaction between multiple organ systems in the body and interpretation of diagnostic testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence in the VA treatment records. As this evidence shows gout only in the left foot, service connection must be denied for gout in the other claimed areas of the left ankle, left and right knees. With regard to the left foot, although there is a current diagnosis of gout, the evidence does not establish in-service injury, event, or illness pertaining to gout, or that this disability began during service or is otherwise related to service. With regard to in-service incurrence, service treatment records are negative for any complaints, treatment, or diagnosis related to gout. Although the Veteran had foot complaints in service, they were not gout-related and are separately service-connected. The Veteran’s has not identified any potential gout symptoms during service, and his April 2013 statement indicates only that he “now” has gout. In an April 2011 VA treatment record, the Veteran identified a date of onset of his left foot or toe gout symptoms of about six years earlier, or decades after service. Although the Veteran believes his left foot gout is related to service, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of medical testing in light of the Veteran’s medical history. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the VA records, which note other potential causes. VA treatment records reflect that, in April 2016, the Veteran reported having several gout flare-ups over the last few months, stating that he was having a lot of stress recently. In a follow-up record in April 2016, he reported eating mostly chicken and pork, and the provider explained that pork is a high purine food and advised that he should limit eating pork because that could be precipitating his gout. There is no need for another medical opinion concerning the Veteran’s gout. In sum, the preponderance of the evidence weighs against finding that the Veteran’s diagnosed left toe gout began during service or is otherwise related to an in-service injury, event, or disease; and weighs against finding a current diagnosis of gout in the left ankle, right or left knees. Therefore, there is no doubt to resolve in his favor, and service connection must be denied. 38 C.F.R. §§ 3.102, 3.303. 7. Entitlement to service connection for hearing loss, right ear. The Veteran claimed service connection for bilateral hearing loss. He was awarded service connection for left ear hearing loss based on medical evidence of a link to his noise exposure in service, but there was no disability found for the right ear. Although the in-service element of service connection has been met, there must also be a current disability that has been linked to the in-service event. Holton, 557 F.3d at 1366. The Veteran has not met the VA disability criteria at any time during the pendency of the claim, or recent in time to the filing of the claim. Romanowsky, 26 Vet. App. at 294; McClain, 21 Vet. App. at 321; 38 C.F.R. § 3.303(a), (d). The auditory threshold for normal hearing is from 0 to 20 decibels, and higher levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). However, impaired hearing is considered a disability for VA purposes only when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; when the auditory thresholds for at least three of these 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. It is not necessary to meet these criteria for a hearing loss disability during service to warrant service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The Veteran has not identified treatment for his hearing loss, and VA treatment records do not reflect any testing or diagnosis of right ear hearing loss. At the September 2013 VA audiological examination, testing for the right ear showed pure tone thresholds ranging from 10 to 25 decibels at all levels from 500 to 4000 Hertz, and speech audiometry revealed speech recognition ability of 98 percent. The VA examination results do not meet the disability criteria, and there is no argument or indication that the Veteran’s hearing in the right ear has worsened. Although the Veteran is competent to report subjective symptoms related to hearing impairment, he is not competent to diagnosis actual hearing loss or to identify the level of his hearing loss because that must be based on objective audiological testing. Jandreau, 492 F.3d at 1376-77; 38 C.F.R. § 3.385. Consequently, the Board gives more weight to the evidence in medical records. As the preponderance of the evidence is against finding a current disability of right ear hearing loss, service connection must be denied. 38 C.F.R. §§ 3.102, 3.303. 8. Entitlement to service connection for sleep condition, to include sleep apnea In his July 2012 claim, the Veteran identified claims for sleep apnea or a sleep condition, as well as a mental health claim identified as PTSD. In the October 2013 rating decision, the AOJ denied service connection for sleep apnea or other sleep condition, noting that the Veteran’s sleep difficulties have been attributed to his depression, which was also denied. The Veteran identified the sleep issue as being appealed in his May 2014 notice of disagreement, but he did not specify a reason, stating only that he wished to appeal all issues and wanted the maximum benefits. The Veteran has not made subsequent assertions concerning sleep apnea or a sleep condition as separate from his mental health disability. The Veteran’s attorney submitted arguments in September 2016 concerning service connection for a mental health disability, which mentions sleep difficulties and is discussed further in the remand section below; however, the attorney did not argue for separate service connection for a sleep condition. The first element of service connection is a current disability. However, the Veteran has not had a diagnosis of sleep apnea or other sleep condition, as separate from symptoms of a mental health disability, at any time during the pendency of the claim or recent in time to the filing of the claim. See Romanowsky, 26 Vet. App. at 294; McClain, 21 Vet. App. at 321; 38 C.F.R. § 3.303(a), (d). VA treatment records reflect complaints of trouble sleeping, including as due to nightmares, worries, and chronic pain. He was diagnosed with mental health disabilities to account for symptoms including chronic sleep impairment. See, e.g., VA treatment records in October 2012, April 2014, May 2015, March 2016. There is no reference to sleep apnea symptoms or diagnosis in the medical records. Although the Veteran is competent to report subjective sleep difficulties, he is not competent to diagnose sleep apnea or other specific sleep condition to account for these symptoms. This issue is medically complex and requires medical knowledge of the interaction between multiple organ systems in the body and interpretation of diagnostic testing. Jandreau, 492 F.3d at 1376-77. Consequently, the Board gives more probative weight to the competent medical evidence in the VA treatment records, which is adequate to address any diagnosis for his sleep difficulties. As the preponderance of the evidence is against finding a current diagnosis of sleep apnea or other sleep condition as separate from symptoms of mental health disability, service connection must be denied. 38 C.F.R. §§ 3.102, 3.303. 9. Entitlement to service connection for a lung condition, to include asthma. In an April 2013 statement, the Veteran described his contentions of having a current lung or breathing disorder as a result of possible exposure to asbestos and lead-based paint from serving in buildings built in the 1930s, chemicals such as gas or smoke, or contaminated water while stationed at Camp LeJeune from 1989 to 1991. He reported that he did not have breathing problems prior to service, he was hospitalized in 2006 for serous breathing problems due to lack of oxygen, and he now needs breathing devices of Symbicort and albuterol (inhalers) daily. The Veteran attributes these problems to the environment while he was in service. The Veteran’s attorney did not make any arguments concerning this claimed disability. The first element of service connection is a current disability. The Veteran is not competent to provide a specific diagnosis for his breathing complaints, to include whether he has an asbestos-related disease. This issue is medically complex and requires medical knowledge of the interaction between multiple organ systems in the body and interpretation of diagnostic testing. Jandreau, 492 F.3d at 1376-77. Consequently, the Board gives more probative weight to the medical evidence. Treatment records reflect that the Veteran’s only diagnosed lung or respiratory condition, at any time during the pendency of the claim or recent in time to the filing of the claim, is asthma. Records of private treatment in 2006 were requested but unavailable, and VA treatment records reflect asthma/allergies. Allergies were noted to be related to animal danders and pollens, and the Veteran reported shortness of breath when consuming some red sauces. Pulmonary function tests (PFTs) and chest X-rays were conducted, including in 2012 for shortness of breath and 2015 for shortness chest pain, and the diagnosis continued to be asthma. See, e.g., records in April 2011, September 2012, October 2012, April 2015. The second element of service connection is an in-service injury, disease, or event. The Veteran has not reported having breathing difficulties during or shortly after service, and his service records do not reflect any such complaints or treatment. He denied having asthma, emphysema, persistent or chronic cough, or shortness of breath for service examinations in December 1988, July 1989, and February 1991. Additionally, although the Veteran is competent to report being exposed to smoke, as that is observable with his own eyes, he is not competent to identify whether he was exposed to asbestos, other non-observable chemicals, or contaminated water. These observations require scientific knowledge. Jandreau, 492 F.3d at 1376-77. Service records do not establish a likelihood of exposure to asbestos or the other asserted chemicals. As noted in adjudicatory documents, a VA asbestos claims memorandum from May 2002 identifies military occupations and probabilities of asbestos exposure; his occupation of rifleman is not among the duties with probable or highly probable exposure. The Veteran’s service records and lay reports also do not reflect an occupation or duties with a likelihood of exposure. In a September 1989 asbestos medical surveillance program questionnaire, the Veteran reported being uncertain as to whether he was exposed to asbestos through construction-type activities, asbestos dust, or working with asbestos or asbestos products. A May 1990 service record then notes the Veteran had not been placed on an asbestos program. An April 2013 official response to a request for any information as to asbestos exposure notes that all available records were sent. The Board notes that constructive-type activities could involve exposure to lead paint or dust; however, the Veteran has not reported any such activities in service. Additionally, although he served after the beginning of the Persian Gulf War period, he did not have any service in the Southwest Asia theater of operations. There is also no evidence in service records to establish exposure to contaminated water. There is a rebuttable presumption that servicemembers who served at Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) from August 1, 1953, to December 31, 1987, were exposed to contaminants in the water supply during such service, and that certain listed diseases are due to such exposure if they became manifest to a degree of 10 percent or more at any time after such service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307(a)(7), 3.309(f). Although the Veteran reports serving at Camp LeJeune from 1989 to 1991, and his service records confirm that he was stationed there for a portion of his service, those times were after the presumptive period for water contamination ended. The Veteran’s assertions of possible contamination are insufficient to establish this element, and there is no other competent evidence to show such exposure. In addition to the in-service element, the final service connection of a nexus to service, by presumption or otherwise, has not been met. The Veteran’s diagnosed asthma and allergies are not among the listed diseases that are subject to presumptive service connection based on any water contamination at Camp LeJeune. See 38 C.F.R. § 3.309(f). There is also no competent evidence to link the current disability directly to service. As noted above, the Veteran has only reported breathing difficulties as being present many years after service. Although the Veteran believes his current disability is due to environmental exposures during service, he is not competent to identify the cause or provide an opinion linking his current asthma or allergies to any water contamination or exposure to asbestos or other chemicals during service. This issue is medically complex, as it requires medical knowledge of the interaction between multiple organ systems in the body. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the VA medical records, which do not reference an asbestos-related disease, and which note other potential causes including dander and pollen. In sum, the preponderance of the evidence weighs against finding that the Veteran’s diagnosed asthma or allergies with breathing difficulties began during service or is otherwise related to an in-service injury, event, or disease, to include on a presumptive basis. Therefore, there is no doubt to resolve in his favor, and service connection must be denied. 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. Increased Rating VA’s schedular percentage ratings are based on average impairment of earning capacity as a result of service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations 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. All reasonable doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The most relevant information for an initial rating pertains to the severity of the disability since the effective date of service connection. Fenderson v. West, 12 Vet. App. 119 (1999). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings may be awarded if there are decreases or increases in symptomatology that meet the criteria for a different rating for a distinct period during the appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). This decision focuses on the evidence pertinent to the rating criteria and disability severity during the relevant periods on appeal; however, the Board has considered the entire record and history to have a full picture of the disabilities. See 38 C.F.R. §§ 4.1, 4.2, 4.41; see also Gonzales v. West, 218 F. 3d 1378 (Fed. Cir. 2000). 10. through 15. Entitlement to higher initial or increased evaluations for right and left leg disabilities: more than 50 percent each for right knee and left knee disabilities; more than 20 percent each for right and left ankle disabilities; and a compensable evaluation for right and left foot disabilities. In his July 2012 claim, the Veteran identified claims for “stress fractures [in] both knees” and “bilateral ankle/foot condition.” In an April 2013 statement and during the July 2013 VA examination, the Veteran described pain and other symptoms involving his feet, ankles, and knees. He identified treatment for turning his left ankle in 2002, which were requested but were unavailable. The Veteran reports for his claim are generally consistent with information in VA treatment records dated since 2011, and there is no indication that his condition has changed in severity. In the October 2013 rating decision, the AOJ awarded assigned ratings of 50 percent each for both knees, 20 percent each for both ankles, and a noncompensable (0 percent) rating for each foot. The Veteran identified these issues as being appealed in his May 2014 notice of disagreement, but he did not specify a reason, stating only that he wished to appeal all issues and wanted the maximum benefits available. The Veteran has not made subsequent assertions concerning why a higher or separate rating would be warranted for his service-connected knee, ankle, or feet disabilities. His attorney also did not make any arguments concerning the ratings for the knees, ankles, or feet. Throughout the appeal period, the Veteran’s ratings of 50, 20, and 0 percent for disabilities of each lower extremity combined to 60 percent. 38 C.F.R. § 4.25. Under the amputation rule, the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. 38 C.F.R. § 4.68. Amputation at the middle or lower third of the leg would be rated at 60 percent. 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5164. Moreover, the assigned ratings of 50 percent for each knee are the maximum for limited extension (DC 5261), and the ratings of 20 percent for each ankle are the maximum allowed for limited motion of the ankle (DC 5271). These assigned ratings included consideration of both subjective and objective evidence, as well as the Veteran’s additional impairment or loss of range of motion due to pain and other factors after repetitive use or flare-ups. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a. Although the Veteran was assigned a noncompensable rating for each foot despite reporting significant foot pain and swelling at times, his reports and medical records indicate these symptoms were generally due to gout or infection, which is not service-connected. The July 2013 VA examiner identified bilateral weak foot and attributed the condition to limited motion from the ankle disabilities. The Board acknowledges that, generally, a separate or higher rating may be assigned based on non-overlapping conditions and symptoms, if the compensable criteria under applicable diagnostic codes are met, including with consideration of additional functional loss after repetitive use or flare-ups for musculoskeletal conditions based on range of motion. See 38 C.F.R. §§ 4.14, 4.40, 4.45, 4.59, 4.71a; see also Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009); Thompson v. McDonald, 815 F.3d 781 (Fed. Cir. 2016). Nevertheless, to the extent that the Veteran may have any such additional symptoms affecting his knees, ankles, or feet, no further discussion is required because such a rating is not allowed. As noted above, a higher rating for the Veteran’s lower extremity disabilities is prohibited by the amputation rule because he is already receiving the combined rating of 60 percent that would be applied if he did not have that portion of his leg. In sum, there is no reasonable doubt to be resolved, and a higher initial or increased evaluation for the Veteran’s bilateral knee, ankle, and foot disabilities must be denied. 38 C.F.R. §§ 4.3, 4.68, 4.71a. 16. Entitlement to an initial evaluation of more than 10 percent for tinnitus. The Veteran identified the evaluation of tinnitus as being appealed in his May 2014 notice of disagreement, but he did not specify a reason, stating only that he wished to appeal all issues and wanted the maximum benefits available. He has not made subsequent assertions concerning why a higher rating would be warranted for tinnitus, and his attorney also did not make any arguments concerning this rating. The Veteran has been assigned the maximum 10 percent schedular rating for his bilateral tinnitus, which encompasses sounds related to tinnitus that are perceived as being in one ear, both ears, or in the head generally. 38 C.F.R. § 4.87, DC 6260 & Note (2); see also Smith v. Nicholson, 451 F.3d 1344, 1348 (Fed. Cir. 2006). The AOJ interpreted the Veteran’s request for a higher rating for tinnitus as raising entitlement to an extraschedular evaluation under 38 C.F.R. § 3.321(b). However, the mere request for a higher rating does not necessarily trigger such a request. There are no assertions or evidence that the Veteran’s tinnitus has symptoms or severity that are not contemplated by the rating schedule. During the September 2013 VA examination, he reported ringing in the ears that affects work and daily activities because it is bothersome. The assigned rating addresses those complaints. In sum, there is no reasonable doubt to be resolved, and an initial evaluation higher than 10 percent for bilateral tinnitus must be denied. 38 C.F.R. §§ 4.3, 4.87. 17. Entitlement to an initial compensable evaluation for hearing loss, left ear. The Veteran appealed from the initial rating assigned for his left ear hearing loss. He has not submitted additional evidence or specified why he believes a higher rating is warranted, and his attorney did not make arguments in that regard. Disability ratings for hearing loss are assigned based on the results of a controlled speech discrimination (Maryland CNC) test combined with the results of pure tone audiometry tests, which must be conducted by a state-licensed audiologist, without the use of hearing aids. See 38 C.F.R. § 4.85. Schedular ratings for hearing impairment are assigned through the mechanical application of the rating schedule to numeric designations that are assigned based on the results of audiometric evaluations. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). A Roman numeral designation of I through XI is assigned for the level of hearing impairment in each ear. Generally, Table VI is used to determine a Roman numeral designation based on a combination of the speech discrimination percentage and the average pure tone threshold, or the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. 38 C.F.R. §§ 4.85(b), (d). After a Roman numeral designation is assigned for each ear using the appropriate Table(s), Table VII is used to determine the compensation rate by combining such designations for hearing impairment in both ears. 38 C.F.R. § 4.85(e). Where only one ear is service-connected, Level I is assigned for the nonservice-connected ear to determine the appropriate rating. 38 C.F.R. § 4.85(f). In this case, the September 2013 VA examination showed left ear pure tone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 Average LEFT 20 20 20 40 25 Speech audiometry revealed left ear speech recognition ability of 98 percent. Applying Table VI, these results yield a designation of Level I hearing loss in the left ear. Level I is also assigned for the nonservice-connected right ear to determine the appropriate rating. Applying Table VII, hearing loss at Level I in both ears yields a noncompensable rating. 38 C.F.R. § 4.85. There are no other hearing test results and no indication that the Veteran’s left ear hearing loss has worsened. The Veteran described his hearing loss at the VA examination as impacting his work and daily activities due to some difficulty understanding speech in background noise. These reports are competent and credible, but they are contemplated by the rating schedule and do not establish entitlement to a higher rating. Although the Veteran contends that he should be awarded a higher rating, schedular percentages for hearing loss are based solely on mechanical application of the audiometric data to the rating formula. Lendenmann, 3 Vet. App. at 349. In sum, there is no reasonable doubt to be resolved, and an initial compensable evaluation for left ear hearing loss must be denied. 38 C.F.R. §§ 4.3, 4.85. Effective Date Unless specifically provided otherwise in applicable law, 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 shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application for said benefits. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Generally, a claim for VA benefits must be submitted on the specific form prescribed by VA’s Secretary, known as a formal claim. 38 C.F.R. § 3.151. However, prior to March 24, 2015, VA also allowed informal claims based on any communication or action, by a veteran or other claimant, his or her authorized representative with a valid VA power of attorney, or a member of Congress, that indicated an intent to apply for a benefit under laws administered by VA and identified the benefit sought. 38 C.F.R. §§ 3.1(p), 3.155(a), (b) (in effect prior to March 24, 2015). Both an informal and formal claim must be in writing to constitute a valid claim. Rodriguez v. West, 189 F.3d 1351, 1354 (Fed. Cir. 1999). 18. through 23. Entitlement to an effective date prior to July 3, 2012, for the grants of service connection for chondromalacia patella, right knee; right ankle strain; bilateral tinnitus; subluxation of fifth MTP joint, right foot; left foot erosion; and hearing loss, left ear. The Veteran identified the effective dates for all service connection awards in the October 2013 rating decision as being appealed in his May 2014 notice of disagreement, but he did not specify a reason, stating only that he wished to appeal all issues and wanted the maximum benefits available. He has not made subsequent assertions as to why an effective date earlier than July 3, 2012, is warranted, and his attorney also did not make any arguments as to the assigned effective dates. In addition to the above general provision, the effective date for an award of disability compensation based on direct service connection is the day following separation from active service or the date entitlement arose, if claim is received within one year after separation from active duty; otherwise, it is the date of receipt of claim, or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(b)(2). In this case, VA first received a claim for service connection for right knee, right ankle, right foot, left foot, tinnitus, and hearing loss disabilities in a VA Form 21-526 on July 3, 2012. This was many years after the Veteran’s discharge from service in 1991. The AOJ previously adjudicated claims for left ankle and left knee disabilities, as discussed below concerning those issues, but there is no assertion or indication of a prior informal claim for these six disabilities. Thus, the date of claim is the proper effective date, and the claims must be denied. Id. 24. Entitlement to an effective date prior to July 3, 2012, for the grant of service connection for patellofemoral pain syndrome, left knee. Neither the Veteran nor his attorney has provided a reason or argument as to why an earlier effective date should be assigned for the award of service connection for his left knee disability. However, slightly different rules apply than for the other claims because the AOJ previously denied the claim for a left knee disability. A rating action by the AOJ is final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 U.S.C. § 5104; 38 C.F.R. § 3.104(a). The claimant has one year from notification of an AOJ decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.160(d), 20.200-20.202, 20.302, 20.1103. The Veteran filed an initial claim for service connection for a left knee disability in October 1991, within one year after his discharge from service. In a November 1991 rating decision, the AOJ denied that claim, and the Veteran was notified of the denial and his appellate rights at that time, and he did not submit evidence or initiate an appeal. However, in April 1992, the AOJ received additional relevant service records, which required de novo reconsideration of that denial under 38 C.F.R. § 3.156(c). In December 1992, the AOJ sent the Veteran three letters: two letters concerned a scheduled VA examination and notified him that the claim may be disallowed if he did not report for that examination, and a third letter request information about a pre-service motor vehicle accident in 1987. The above letters were not returned as undeliverable. However, the Veteran’s mother submitted a statement in January 1993 in response to the examination notification letter, stating that he had moved to New Jersey and was unable to attend. The AOJ then resent the December 1992 letter requesting information about the pre-service accident to the newly identified address in New Jersey. In June 1996, the Veteran submitted a statement that he had filed a claim in October 1991 in Colorado and had not heard anything about it. He requested an examination and identified a different address in Colorado. In August 1996, the AOJ resent a copy of the November 1991 letter with the denial of the claim for a left knee disability and appellate rights to the newly identified address. An examination was scheduled for September 1996, but the Veteran failed to report. In September 1996, the AOJ sent the Veteran a letter to his most recently identified address in Colorado, explaining that he had failed to report for the September 1996 examination that was scheduled for his claim, that the available evidence was insufficient to decide the claim, and that no further action would be taken unless the AOJ received information of his willingness to report for an examination. The letter explained that this request must be received by September 1997, and that any request after that date would be considered a new claim and any benefits granted based on that claim could not start before date of that new claim. The letter included notice of the Veteran’s right to appeal from this determination. The Veteran did not submit the requested evidence within one year after the date of the request; thus, the claim was considered abandoned. 38 C.F.R. § 3.158(a). The effective date for a subsequent grant of benefits can be no earlier than the receipt of the reopened claim after an abandoned claim. Fleshman v. Brown, 9 Vet. App. 548, 553 (1996) (J. Kramer, concurrence), aff’d Fleshman v. West, 138 F. 3d 1429 (Fed. Cir. 1998). Additionally, the Veteran did not appeal from that determination, and there is no argument or indication that he did not receive those notice letters. After the September 1996 denial and abandonment of the claim, VA received a formal claim (VA Form 21-526) for a left knee disability on July 3, 2012. There is no argument or indication of a prior informal claim for this disability. Therefore, the proper effective date is July 3, 2012, the date of the claim to reopen that led to the grant of service connection, and the claim is denied. 38 C.F.R. § 3.400(r). 25. Entitlement to an effective date prior to July 3, 2012, for the increased evaluation for residuals of injury, left ankle. Neither the Veteran nor his attorney has provided a reason or argument as to why an earlier effective date should be assigned for the award for his left ankle disability. However, slightly different rules apply for increased rating claims. If an increase in disability level was factually ascertainable within one year prior to receipt of the increased rating claim, then the effective date will be the date on which that increase is shown to have occurred; otherwise, the effective date will be the date of receipt of the claim. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); see also Gaston v. Shinseki, 605 F.3d 979, 983-84 (Fed. Cir. 2010) (noting that this provision provides a one-year grace period for a claim for an increase in severity). The AOJ granted service connection and an initial noncompensable rating for the Veteran’s left ankle disability in a November 1991 rating decision. As with the left knee as discussed above, the Veteran was notified of the determination and his appellate rights at that time, but he did not appeal. Additional service records were received in April 1992, and the AOJ requested a VA examination concerning the severity of the left ankle in December 1992, which was not completed. The AOJ resent the November 1991 denial letter with appellate rights to the Veteran’s newly identified address in August 1996, along with notification of a VA examination, and notified the Veteran in September 1996 that his failure to appear for the scheduled examination meant there was insufficient evidence to adjudicate the claim. The Veteran did not respond to that notice within one year or appeal from that determination. Therefore, the claim was abandoned in 1996, and the initial rating assigned in 1991 became final. See 38 C.F.R. §§ 3.104, 3.158(a), 3.160. After the September 1996 determination, VA received the Veteran’s formal claim for an increased rating for the left ankle (VA Form 21-526) on July 3, 2012. There is no argument or indication of a prior informal claim for this disability, or that the increase of severity to 20 percent occurred within one year prior to this claim. VA treatment records starting in 2011 reflect ongoing reports of pain, swelling, and other symptoms in the left ankle, and range of motion measurements to show marked limitation of motion of the ankle were first recorded in the 2013 VA examination. The Veteran reported severe left ankle problems and turning his ankle with treatment in 2002, but he did not a submit a claim for increased rating at that time. Furthermore, his treatment was at a private facility and records were not submitted, such that the treatment itself could not have been construed as an informal claim. See 38 C.F.R. § 3.157(b) (as in effect prior to March 24, 2015). Therefore, the proper effective date is July 3, 2012, the date of the claim for increase after the last final denial because the increase was not factually ascertainable within one year prior to that claim. 38 C.F.R. § 3.400(o)(2). REASONS FOR REMAND 1. Service connection for acquired psychiatric disorder, to include PTSD or major depressive disorder, is remanded. More information is needed to allow the Board to make a fully-informed decision for the Veteran’s mental health claim, which has been claimed as either directly due to service or secondarily related to pain from service-connected disabilities. The Veteran has not been provided a VA examination for this claim, and the current medical evidence is insufficient to establish direct or secondary service connection. It is unclear whether the Veteran has a current diagnosis of PTSD under the DSM-5, or whether any such diagnosis is related to in-service events, as opposed to non-service related stressful events noted in the record. Additionally, VA has not yet attempted to corroborate one a reported in-service stressor. VA treatment records since 2011 include notations of PTSD or major depressive disorder rule out PTSD, in addition to other diagnosed conditions. The Veteran reported significant non-military stressful events of multiple suicides of family members and friends (including prior to service and in 2003 and 2014), financial and other situational concerns, and symptoms related to those stressors. However, the Veteran also reported combat-type experiences while deployed to Liberia or West Africa and that his girlfriend passed away in service. He reported feeling confused, anxious, and lacking purpose since leaving the military, as well as that he believed his depression started in service and was perpetuated by family losses. He described having alcohol and legal problems in the 1990s when he was unable to discuss service events, and that he had depression off and on for approximately 20 years (or since the 1990s). See, e.g., VA records in September 2012, October 2012, April 2014, May 2015, February 2016. An April 2011 initial VA record noted positive PTSD and alcohol screens, but no further treatment at that point. Service records reflect that the Veteran denied mental health symptoms in his enlistment examination and in a July 1989 overseas screening examination. The DD Form 214 reflects six months of sea service and no combat citations or awards. Service treatment records show that he was assigned to the U.S.S. Sumter (LST-1181) for several months in 1990, and a service personnel record reflects that he participated in contingency for Operation Sharp Edge off the coast of Liberia from June to August 1990. A February 1991 service treatment record noted that the Veteran was in a fight and had alcohol on his breath. The Veteran denied nervousness in a February 1991 dental health questionairre, but service records do not include a full examination with Report of Medical History, including any mental health symptoms, near his May 1991 discharge date. The Veteran was discharged based Medical Evaluation and Physical Evaluation Boards for left ankle and knee disabilities, shown by November 1990 and April 1991 documentation. The Veteran did not respond to the March 2013 request for additional information concerning his PTSD claim, including by way of a VA Form 21-0871. However, VA treatment records reflect that he described distressing events during a deployment to Liberia or West Africa during service. Although he only made a vague report of being in combat in Liberia in September 2012, he provided additional details for treatment in 2015 and 2016. In May 2015, the Veteran stated that he felt helpless to save people during this deployment, felt like his life was in danger, and witnessed some things he did not want to talk about, and that he has some nightmares about his experiences and did not like talking about some of the experiences. In July 2015, he reported witnessing “brutal acts” in Liberia and that he had nightmares and memories of experiences overseas and avoided watching the news. In February 2016, the Veteran reported that questioning during a deposition for a recent accident brought back memories of incidents in service in Liberia, and that he had nightmares about mutilated bodies that night. He continued reported increased symptoms and nightmares in March 2016. Additional development is warranted concerning the reported stressor related to deployment to Liberia, which current records show was from June to August 1990. Thereafter, a VA examination should be provided to determine the current diagnosis and address whether any PTSD is due to any verified combat, corroborated stressor, or a fear of military hostile or terrorist activity. See 38 C.F.R. § 3.304(f). Other diagnosed mental health disability does not require a verified or corroborated stressor, but there must still be credible evidence of an in-service event and competent evidence linking the current disability to service. Concerning secondary service connection, the Veteran has also reported difficulty sleeping more than 2-4 hours per night, as well as feelings of hopelessness, due in part to chronic pain and functional limitations. See, e.g., VA records in October 2012, May 2015. He has significant impairment from service-connected disabilities, as reflected by his combined 90 percent rating, as well as multiple significant nonservice-connected disabilities. The Veteran’s attorney also submitted arguments in September 2016 that the current major depressive disorder is secondary to service-connected physical disabilities. The attorney submitted a September 2015 private evaluation and residual functional capacity assessment by a psychologist, which diagnoses major depressive disorder recurrent moderate under the DSM-V and opines that the service-connected disabilities are more likely than not causing the Veteran’s major depressive disorder. This evaluation also notes that the Veteran reported having no depression or anxiety prior to service, and that VA treatment records reflect reports of mental health symptoms that began during service and difficulty sleeping due to pain and other factors, which is also relevant to whether there is a direct connection to in-service experiences. This private evaluation reflects review of VA treatment records and examinations and cites to medical literature; however, it does not mention the Veteran’s many other stressful events after service as noted in the VA treatment records. Therefore, it is probative but insufficient to establish service connection. Nevertheless, there is some information to suggest that there may be a link between the current mental disability and service or service-connected disabilities, based on information in the VA treatment records and service records in addition to this private evaluation. Therefore, a VA examination and opinion is warranted, as well as additional development concerning the Veteran’s reported in-service stressor. 2. Entitlement to TDIU is remanded. The Veteran’s attorney argued in September 2016 that the new private evaluation dated in September 2015 reflects that the service-connected disabilities and major depressive disorder, claimed as secondary to those disabilities, prevents him from being employed. The private evaluation also notes that the Veteran last worked in 2012. As explained above, the issue of TDIU is under the Board’s jurisdiction as part of the appeal for the underlying ratings; it is also inextricably intertwined with the mental health claim because as a decision on the mental health issue could significantly impact the TDIU decision. Development and adjudication is required. The matters are REMANDED for the following action: 1. Attempt to corroborate the Veteran’s in-service stressor related to his deployment to Liberia aboard the U.S.S. Sumter (LST-1181) for Operation Sharp Edge from June to August 1990. If more details are needed, contact the Veteran to request the information. 2. Thereafter, schedule the Veteran for a psychiatric examination to determine the nature and etiology of any current mental health disability, to include PTSD or major depressive disorder. If the PTSD is diagnosed, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not directly related to either a verified in-service stressor or to a fear of hostile military or terrorist activity. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. The examiner is advised that verification of the stressor is not required for non-PTSD disabilities, but there must be an in-service event, symptoms, or other reason for a link to service. The examiner should also opine whether any currently diagnosed disorder, to include PTSD or major depressive disorder, is at least as likely as not proximately caused by or aggravated beyond its natural progression chronic pain and impairment from the service-connected disabilities. The examiner should address the significance of non-military stressful events in addition to other relevant evidence, and should consider the private mental health evaluation and opinions submitted in September 2016. 3. Provide notice, conduct appropriate development, and adjudicate the TDIU claim, to include as based on the service-connected physical disabilities and also with consideration of the claimed mental health disability. 4. After completing the above development, readjudicate the issues remanded, to include the inextricably intertwined TDIU. If the benefits sought are not granted to the Veteran’s satisfaction, provide a Supplemental Statement of the Case before returning the case to the Board for further appellate review, if necessary. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Wheatley