Citation Nr: 18149598 Decision Date: 11/09/18 Archive Date: 11/09/18 DOCKET NO. 16-40 976 1DATE: November 9, 2018 ORDER New and material evidence having been received, the previously denied claim of entitlement to service connection for a right knee/leg disorder (claimed as secondary to service-connected left knee osteoarthritis) is reopened and service connection is granted. New and material evidence having been received, the previously denied claim of entitlement to service connection for a left hip disorder (claimed as secondary to service-connected left knee osteoarthritis) is reopened and service connection is granted. New and material evidence having been received, the previously denied claim of entitlement to service connection for a lumbar spine disorder (claimed as secondary to service-connected left knee osteoarthritis) is reopened and service connection is granted. Service connection for a right hip disorder (claimed as secondary to service-connected left knee osteoarthritis) is denied. Service connection for lung cancer is denied. Service connection for sleep apnea is granted. Service connection for hypertension is granted. Service connection for depression is granted. A compensable disability rating for bilateral hearing loss is denied. REMANDED A disability rating greater than 30 percent for osteoarthritis, left knee is remanded. FINDINGS OF FACT 1. In a September 2011 Board decision, service connection for a right leg/knee disorder was denied and, in a final July 2014 rating decision, service connection for left hip and lumbar spine disorders was denied. 2. Evidence added to the record since the September 2011 and July 2014 denials is not cumulative or redundant of the evidence of record at the time of the decisions and raises a reasonable possibility of substantiating the Veteran’s claims of entitlement to service connection for right leg/knee, left hip, and lumbar spine disorders. 3. Resolving all doubt in his favor, the Board finds that the Veteran has a current diagnosis of right knee, left hip, and lumbar spine disorders which have been related to his service-connected left knee disorder. 4. The available medical evidence does not demonstrate that the Veteran has, or at any pertinent point during the current appeal period has had, a diagnosis of a right hip disorder. 5. There is no evidence of lung cancer in service and no competent evidence linking the Veteran’s current residuals of lung cancer with his period of service, to include a service-connected disability. 6. Resolving all doubt in his favor, the Veteran has a current diagnosis of sleep apnea which has been related to the Veteran’s service-connected disabilities. 7. Resolving all doubt in his favor, the Veteran has a current diagnosis of hypertension which has been related to the Veteran’s service-connected disabilities. 8. Resolving all doubt in his favor, the Veteran has a current diagnosis of depression which has been related to the Veteran’s service-connected disabilities. 9. The Veteran has no more than Level II hearing loss in the right ear and Level III hearing loss in the left ear, evaluated as non-compensable. CONCLUSIONS OF LAW 1. The September 2011 Board decision that denied service connection for a right leg/knee disorder and the July 2014 rating decision that denied service connection for left hip and lumbar spine disorders are final. 38 U.S.C. § 7104 (b); 38 C.F.R. § 20.1100(a), 20.1104. 2. New and material evidence has been received to reopen the claims of entitlement to service connection for right leg/knee, left hip, and lumbar spine disorders. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for the establishment of service connection for right leg/knee, left hip, and lumbar spine disorders are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for a right hip disorder are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for service connection for lung cancer have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 6. The criteria for the establishment of service connection for sleep apnea are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. 7. The criteria for the establishment of service connection for hypertension are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. 8. The criteria for the establishment of service connection for depression are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. 9. The criteria for a compensable disability rating for bilateral sensorineural hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.385, 4.1-4.7, 4.21, 4.85, Diagnostic Code (DC) 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1990 to March 1992. This matter comes before the Board of Veterans’ Appeals (Board) from a June 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. New and Material Evidence With regard to the right leg/knee claim, the Veteran submitted an original claim for service connection for a right leg/knee disorder in January 2006. By rating decision dated in May 2006, the RO denied service connection for right leg/knee disorders finding that, although the Veteran had been diagnosed with arthritis of the right knee, this occurred after the Veteran’s military service and could not be related to his service-connected left knee disability. The Veteran perfected an appeal of the May 2006 rating decision but, in September 2011, the Board continued the denial. This decision became final on September 13, 2011, the date stamped on the face of the decision. 38 C.F.R. § 20.1100 (a) (a Board decision is final on the date stamped on the face of the decision). With regard to the left hip and lumbar spine issues, the Veteran submitted an original claim for service connection for left hip/lumbar spine disorders in March 2014. By rating decision dated in July 2014, the RO denied service connection for disorders of the left hip and lumbar spine. Again, the RO found that, although the Veteran had been diagnosed with arthritis of the left hip and lumbar spine, this occurred after the Veteran’s military service and could not be related to his service-connected left knee disability. The July 2014 decision advised the Veteran of his appellate rights, however, no further communication regarding this claim was received until December 2015, when VA received an application to reopen such claim. Therefore, the July 2014 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. Generally, a claim which has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The United States Court of Appeals for Veterans Claims (Court) has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary’s duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Board finds that the evidence received since the September 2011 Board decision and July 2014 rating decision is new and material. Specifically, since such decisions, additional evidence addressing the bases of the prior final denials has been received, to include a private medical opinion relating the Veteran’s right knee, left hip, and lumbar spine disorders to his service-connected left knee disorder. As above, the prior denials were based on the fact that, although the Veteran had been diagnosed with arthritis of the right knee, left hip, and lumbar spine, these conditions occurred after the Veteran’s military service and could not be related to his service-connected left knee disability. The evidence received since such time includes an August 2017 statement from Dr. H.S., indicating that such disorders are related to his service-connected left knee disorder. Therefore, the Board finds that the evidence added to the record since the final September 2011 and July 2014 denials is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran’s claims of entitlement to service connection for right leg/knee, left hip, and lumbar spine disorders. Consequently, the Board finds that new and material evidence has been received to reopen the claims for service connection for right leg/knee, left hip, and lumbar spine disorders. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease 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). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Service connection for right leg/knee, left hip, and lumbar spine disorders The Veteran contends that right leg/knee, left hip, and/or lumbar spine disorders are secondary to his service-connected left knee disability. Specifically, he contends that these disabilities are either secondary to or aggravated by years of an altered gait due to his left knee disability. While the Veteran’s service treatment records do show complaints regarding the right knee in October and November 1991, they are negative for a chronic right knee condition and are also negative for complaints regarding the left hip and/or back. The earliest evidence of a chronic right knee disorder is a June 1997 Reserve treatment record noting arthritis in both knees. The earliest evidence of left hip and lumbar spine disorders is a March 2014 VA X-ray showing arthritis of the left hip and lumbar spine. The Veteran was previously afforded VA examinations pertaining to his claimed disorders in March 2010 and June 2014. Significantly, a March 2010 VA knee examiner opined that it was not likely that the diagnosed right knee arthritis is etiologically related to the Veteran’s active service and is not caused or aggravated by his service-connected osteoarthritis of the left knee. The examiner explained that the Veteran was 66 years old and that the degenerative changes of his skeletal system and joints were consistent with his age. Similarly, a June 2014 VA hip/lumbar spine examiner found that these disorders were less likely than not related to the Veteran’s active service and/or a service-connected disability. As rationale for this opinion, the examiner wrote that there was no permanent residual or chronic disability and/or aggravation subject to service connection and that degenerative changes are not interdependent or related to each other. However, a November 2011 VA examination/opinion concerning a claim for service connection for a left ankle disorder suggests that joints do affect one another. Significantly, the November 2011 VA examiner opined that the Veteran’s left ankle disorder was not related to his service-connected left knee disorder. As rationale for this opinion, the examiner wrote that the Veteran was experiencing limping/altered gait secondary to left knee joint pain and having more weight bearing on the right lower extremity, not over the left ankle. In support of the Veteran’s current claim, he submitted an August 2017 statement from Dr. H.S. Dr. H.S. reviewed the claims file in depth, noting that the Veteran was experiencing a significant altered gait due to his service-connected disability. Specifically, Dr. H.S. noted the November 2011 VA ankle examination in which the examiner was found to have “limping gait secondary to left knee joint pain and having more weight bearing on right lower extremity, not over left ankle;” a June 2014 VA examination in which it was noted that the Veteran used a cane for ambulation and had a slow gait with a slight limp; and VA treatment records dated from February 2003 through March 2016 showing that the Veteran’s gait was impaired. Dr. H.S. also noted that medical research had shown that, with limping, there is a shift of the body’s center of gravity toward the affected leg. When weight is transferred to the good leg, the repositioning of the center of gravity in the mid-line is in part due to the pull of the paralumbar and abdominal musculature as well as the left abductor muscles on the normal side. The increased muscle pull increases the force transferred across the lumbar discs, facet joints, hip, knee, and ankle due to mechanical leverage and repetitive pull of the trunk musculature. This could, in time, result in increased wear and tear of the disc segments which would, in turn, cause or aggravate degenerative change (osteoarthritis). The Veteran has had an antalgic gait for several years, as noted in his treatment records, due to his service-connected left knee disability. As a result, he has had several years of favoring ad compensating for his left knee disability, meaning his right knee has been bearing more weight (as noted by the November 2011 VA ankle examiner) and his hip joints and lumbar discs and facet joints have been forced to adjust and become subject to increased wear and tear over the course of several years. As such, based on his review of the claims file, medical research, and decades of medical experience, Dr. H.S. opined that it was as likely as not that the Veteran’s service-connected osteoarthritis of the left knee significantly and materially contributed to his right knee degenerative joint disease, lumbar degenerative arthritis and disc disease, and left hip osteoarthritis. Upon review of the evidence, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for right knee, left hip, and lumbar spine disorders is warranted. As an initial matter, the Board finds that the Veteran has current diagnoses of right knee, left hip, and lumbar spine disorders. Furthermore, there is medical evidence that such disabilities are related to the Veteran’s service-connected left knee disability. Significantly, the August 2017 statement from Dr. H.S. relates the Veteran’s right knee, left hip, and lumbar spine disorders to an altered gait caused by the Veteran’s service-connected left knee disability. Furthermore, as above, the Veteran’s VA treatment records show a history of an altered gait since at least February 2003. While the March 2010 and June 2014 VA examiners opined that the Veteran’s right knee, left hip, and lumbar spine disorders are not related to the Veteran’s service-connected left knee disability, neither examiner considered the Veteran’s altered gait. Accordingly, the Board resolves all doubt in favor of the Veteran and finds that right knee, left hip, and lumbar spine disorders are related to his service-connected left knee disability. Therefore, service connection for right knee, left hip, and lumbar spine disorders is warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303; Gilbert, supra. 2. Service connection for right hip disorder The Veteran contends that service connection is warranted for a right hip disorder. Specifically, he contends that a right hip disorder is either secondary to or aggravated by years of an altered gait due to his left knee disability. A review of the Veteran’s service treatment records is negative for a right hip disorder. Significantly, examinations dated in September 1990, July 1991, and November 1991 show normal lower extremities. The Veteran submitted an initial claim for service connection for a right hip disorder in December 2015. As above, the Veteran was diagnosed with left hip arthritis in March 2014. However, while VA treatment records show complaints of right hip pain, these records are negative for a right hip disorder. Significantly, a June 2014 VA examination of the hips shows a diagnosis of left hip arthritis but shows normal findings regarding the right hip. The question for the Board is whether the Veteran has a current right hip disorder that began during service or is at least as likely as not related to an in-service injury, event, or disease. In this case, the Board concludes that the Veteran does not have a current diagnosis of a right hip disorder and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). While the Veteran has reported right hip pain, pain (absent functional loss resulting in impairment in earning capacity) is not a disability for which VA compensation can be awarded. See Saunders v. Wilkie, 886 F.3d 1356 (Fed, Cir. 2018). Also, while the Veteran believes he has a current diagnosis of a right hip disorder, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body/the ability to interpret complicated diagnostic medical 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. Accordingly, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection for a right hip disorder. As the evidence is not in relative equipoise, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Service connection for lung cancer The Veteran alleges that he has current residuals of lung cancer which is related to his military service. Unfortunately, he has not explained why he believes that his lung cancer is related to his service. The Veteran’s service treatment records are negative for any lung problems. Significantly, the Veteran’s November 1991 separation examination shows normal “lungs and chest,” in a November 1991 report of medical history, the Veteran specifically denied “shortness of breath,” “pain or pressure in chest,” and “chronic cough.” Post-service treatment records show that the Veteran was diagnosed with squamous cell carcinoma, moderately differentiated, of the right lower lobe lung in 2014 and underwent right thoracoscopy with right lower lobe wedge resection with mediastinal lymph node dissection in October 2014. He underwent a CT (computed tomography) scan in January 2015 which revealed increasing bilateral lung nodules and mediastinal lymphadenopathy. A repeat CT in March 2015 showed improvement in the infiltrative process seen on previous examination. Upon review of the evidence, the Board finds that service connection for residuals of lung cancer is not warranted. While the Veteran contends that his lung cancer is related to his military service, he has not explained why he believes that it is related to his service. Significantly, his service treatment records are negative for any complaints, treatment, or findings referable to lung problems. Furthermore, the Veteran was not diagnosed with lung cancer until 2014, approximately 22 years after his discharge from military service. In addition, the evidence does not show, nor does the Veteran allege, that he continuously manifested symptoms related to his claimed disability after service. In this context, the Board notes that the passage of several years between discharge from active service and the medical documentation of the claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 36 (1992). Moreover, there is no medical opinion linking the Veteran’s lung cancer to his military service and the Veteran’s mere conclusory generalized lay statement that a service event caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, the Veteran’s claim for service connection for residuals of lung cancer must be denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 4. Service connection for sleep apnea The Veteran contends that sleep apnea is secondary to his service-connected disabilities. VA treatment records show that the Veteran was diagnosed with sleep apnea in approximately April 2011. In connection with this claim, the Veteran submitted an August 2017 statement from Dr. H.S. Significantly, Dr. H.S. reviewed the claims file and opined that it was more likely than not that the Veteran’s sleep apnea is secondary to the Veteran’s service-connected left knee disability, to include medication used to treat his left knee disability, as well as his depression, hypertension, and other joint disorders, for which service connection is being granted in this decision. Initially, Dr. H.S. noted that the Veteran is service-connected for osteoarthritis of the left knee. He also suffers from chronic right knee, left hip, and lumbar pain as well as depression and hypertension. The Veteran is prescribed Oxycodone (an opiate) for his chronic pain and Mirtazapine (a tetracyclic antidepressant) for his depression symptoms. The Veteran also complained of inability to sleep and disrupted sleep. Dr. H.S. also noted that medical research has repeatedly shown that chronic pain and disrupted sleep are commonly associated and share a clear cause and effect relationship. Pain fragments sleep and poor sleep worsens the pain response. Also, long term narcotic use for pain causes, precipitates, or exacerbates sleep disordered breathing. Opiates, such as Oxycodone, bind to various opioid receptors within the nervous system and elsewhere in the body. They result in increased respiratory pauses, irregular breathing, and shallow breaths. Research has also shown that psychiatric disorders are commonly associated with obstructive sleep apnea. A recent study found that subjects with depression, compared with non-depressed controls, have a higher prevalence of sleep apnea diagnosis. This study found that with CPAP (continuous positive airway pressure) treatment, both obstructive sleep apnea and psychiatric symptoms decreased, providing further evidence of the co-morbidity of these conditions. Additionally, the Veteran’s prescribed treatment for his psychiatric condition, Mitrazapine, is associated with sedation. Research shows all sedative drugs suppress the central nervous system, which is typically accompanied by a reduction in carbon dioxide responsiveness in the medullary respiratory center. Respiratory depression further increases when combining sedative drugs. Since sleep apnea, itself, is a serious disorder in which breathing is paused or shallow during sleep, the introduction of medication which results in respiratory pauses, irregular breathing, and shallow breaths increases the risk for harmful respiratory events. Finally, research shows obstructive sleep apnea is more prevalent in patients with hypertension than in the general population and many with obstructive sleep apnea also have hypertension. When Dr. H.S. spoke with the Veteran in August 2017, the Veteran told him that, at least three nights per week, he cannot use his CPAP due to his depressive disorder. When his depression is bothering him a great deal, the CPAP makes him feel claustrophobic and he cannot tolerate it. The Veteran also reported that he had difficulty falling asleep nightly due to his knee, back, and hip pain and pain will often wake him in the night. These are very common problems for patients who have mental health issues and chronic pain along with sleep apnea. His inability to use his CPAP every night and delayed onset of sleep with frequent night time awakenings greatly aggravates the effects of his sleep apnea and the next day he is very tired and will fall asleep frequently. His tiredness also adversely affects his depression and pain perception. Based on his experience, his interview with the Veteran, a review of the Veteran’s medical records, and supporting literature, Dr. H.S. opined that it was as likely as not that the Veteran’s depression, chronic pain, opioid pain medication, and antidepressant medication, and hypertension aided in the development of and permanently aggravated his sleep apnea. Significantly, Dr. H.S. included medical treatise evidence noting a relationship between sleep apnea and chronic pain, prescription medications, and psychiatric disabilities. Upon review of the evidence, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for sleep apnea is warranted. As an initial matter, the Board finds that the Veteran has a current diagnosis of sleep apnea. Furthermore, there is medical evidence that such disability is related to the Veteran’s service-connected left knee disability, to include medication used to treat his left knee disability, as well as his depression, hypertension, and other joint disorders, for which service connection is being granted in this decision. Significantly, the August 2017 opinion from Dr. H.S. provides a well-reasoned rationale with supporting medical treatise evidence. Accordingly, the Board resolves all doubt in favor of the Veteran and finds that sleep apnea is related to his service-connected disabilities. Therefore, service connection for sleep apnea is warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303; Gilbert, supra. 5. Service connection for hypertension The Veteran contends that hypertension is secondary to his service-connected disabilities. VA treatment records show that the Veteran was diagnosed with hypertension in approximately November 2003. In connection with this claim, the Veteran submitted an August 2017 statement from Dr. H.S. Significantly, Dr. H.S. reviewed the claims file and opined that it was more likely than not that the Veteran’s hypertension is secondary to the Veteran’s service-connected left knee disability and other joint disorders, for which service connection is being granted in this decision. Initially, Dr. H.S. noted that the Veteran is service-connected for osteoarthritis of the left knee as well as various other nonservice-connected joint disorders which have resulted in chronic pain. Dr. H.S. also noted that research had shown that chronic pain may be associated with increased risk of hypertension. Though, in healthy individuals, elevated blood pressure is associated with diminished pain sensitivity, these cardiovascular/pain regulatory system interactions appear altered in patients with chronic pain and elevated blood pressure is associated with increased acute and chronic pain responsiveness. The Veteran suffers from hypertension which remains uncontrolled in spite of an aggressive medication regimen. Based on his review of the claims file, medical research, and decades of medical experience, Dr. H.S. opined that it was as likely as not that the Veteran’s chronic pain from his service-connected osteoarthritis of the left knee as well as his chronic pain from his right knee, lumbar spine, and left hip disabilities, have substantially and materially contributed to his hypertension. Significantly, Dr. H.S. included medical treatise evidence noting a relationship between hypertension and chronic pain. Upon review of the evidence, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for hypertension is warranted. As an initial matter, the Board finds that the Veteran has a current diagnosis of hypertension. Furthermore, there is medical evidence that such disability is related to the Veteran’s service-connected left knee disability, as well as right knee, lumbar spine, and left hip disorders, for which service connection is being granted in this decision. Significantly, the August 2017 opinion from Dr. H.S. provides a well-reasoned rationale with supporting medical treatise evidence. Accordingly, the Board resolves all doubt in favor of the Veteran and finds that hypertension is related to his service-connected disabilities. Therefore, service connection for hypertension is warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303; Gilbert, supra. 6. Service connection for depression The Veteran contends that depression is secondary to his service-connected disabilities. VA treatment records show treatment for depression as early as 2011. In connection with this claim, the Veteran submitted an October 2017 disability benefits questionnaire and statement from Dr. H.H.G. Significantly, Dr. H.H.G. diagnosed major depressive disorder, recurrent, with psychotic features. Dr. H.H.G. reviewed the claims file and opined that it was more likely than not that the Veteran’s major depressive disorder began in military service and continues uninterrupted to the present and is aggravated by his osteoarthritis of the left knee, tinnitus, bilateral hearing loss, lumbar spine/bilateral hip/right knee disorders, sleep apnea, and hypertension. As rationale for the direct service connection opinion, Dr. H.H.G. noted that there was a body of literature detailing the emergence of mental health symptoms within active duty servicemen, specifically, that active military service impacts depression, anxiety, and quality of life satisfaction. Additionally, other researchers revealed that guilt is a salient feature in mental health diagnoses of active duty military personnel. In fact, active duty military personnel become disillusioned with their personal and professional identities and, as a result of the chronic guilt and shame associated with their service identities, have more mental health events than civilians. As rationale secondary service connection opinion, Dr. H.H.G. noted that there was a body of literature detailing the connection between medical issues, like the issues that the Veteran struggles with, and a psychiatric disorder, similar to the Veteran’s major depressive disorder. In fact, there is a causal relationship between medical and psychiatric difficulty. Moreover, individuals with medical issues and major depressive disorder debilitation become disabled due to the holistic effect of medical and psychiatric disturbances, just like the Veteran’s osteoarthritis of the left knee, tinnitus, bilateral hearing loss, lumbar spine/bilateral hip/right knee disorders, obstructive sleep apnea, hypertension and secondary major depressive disorder endured by the Veteran renders him incapacitated. Numerous research studies also document that hearing loss has a significant biopsychosocial impact on quality of life, including employment. Additionally, psychologically, people with hearing loss are more inclined to experience depression, anxiety, anger, frustration, and social isolation and loneliness. There is a body of literature detailing the association between tinnitus and comorbid psychological disorders, including a high prevalence of anxiety and depression in tinnitus sufferers. The consequences of tinnitus include emotional effects, reduced involvement in work-related activities, interpersonal problems, and decreased opportunities to engage in previously enjoyable activities. There is also a study showing a correlation between psychological stress (i.e., depression) and obstructive sleep apnea. The authors of this study conclude that sleep apnea and mood disorders should be treated as comorbid disorders as up to 20 percent of all sleep apnea patients also have a diagnosis of depression and vice versa. The authors found that there are several other expected factors, age, gender, and socioeconomic conditions which may even exacerbate that baseline percentage. Hence, a conclusion can be drawn that there is, indeed, a complex correlation between obstructive sleep apnea and depression. Significantly, Dr. H.H.G. included medical treatise evidence noting a relationship between depression and military service, tinnitus pain, hearing loss, and sleep apnea. Upon review of the evidence, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for depression is warranted. As an initial matter, the Board finds that the Veteran has a current diagnosis of major depressive disorder. Furthermore, there is medical evidence that such disability is related to the Veteran’s service-connected left knee disability, hearing loss, and tinnitus, as well as right knee/lumbar spine/left hip disorders and hypertension for which service connection is being granted in this decision. Significantly, the August 2017 opinion from Dr. H.H.G. provides a well-reasoned rationale with supporting medical treatise evidence. Accordingly, the Board resolves all doubt in favor of the Veteran and finds that depression is related to his service-connected disabilities. Therefore, service connection for hypertension is warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303; Gilbert, supra. Increased Rating Disability ratings are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In rating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). A claim for increased rating remains in controversy when less than the maximum available benefit is awarded AB v. Brown, 6 Vet. App. 35 (1993). Reasonable doubt as to the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In a decision, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall resolve reasonable doubt in favor of the claimant. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Impaired hearing will be considered a disability only after threshold requirements are met. See 38 C.F.R. § 3.385. Once disability is established, levels of hearing loss are determined by considering the average pure tone threshold and speech discrimination percentage scores. 38 C.F.R. § 4.85(b). See Lendenmann v. Principi, 3 Vet. App. 345 (1992) (assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered). The provisions of 38 C.F.R. § 4.86 address exceptional patterns of hearing loss. The exceptional patterns addressed in this section are present when the puretone threshold at each of the 4 specified frequencies (1000, 2000, 3000 and 4000 Hz) is 55 decibels or more, or when the puretone threshold is 30 decibels or less at 1000 Hz, and 70 decibels or more at 2000 Hz. The Veteran submitted an initial claim for service connection for bilateral hearing loss in November 2006 and, by rating decision dated in April 2007, the RO granted service connection for bilateral sensorineural hearing loss, assigning a noncompensable disability rating effective November 8, 2006, the day of his claim for service connection. The Veteran submitted the current claim for an increased rating for his service-connected bilateral hearing loss in December 2015. In connection with this claim, he was afforded a VA audiological examination in April 2016. Significantly, with regard to functional impairment, the examiner wrote that the Veteran’s hearing loss did not impact ordinary conditions of daily life, including his ability to work. Audiological testing revealed the following: Puretone Threshold 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 35 dB 40 dB 55 dB 65 dB Left Ear 25 dB 30 dB 50 dB 65 dB Puretone Threshold Average Right Ear 49 dB Left Ear 43 dB Speech Recognition Right Ear 84% Left Ear 80% In the present case, the evidence does not show an exceptional level of impaired hearing; 38 C.F.R. § 4.86 is not applicable because the puretone threshold at each of the 4 specified frequencies (1000, 2000, 3000 and 4000 Hz) is not 55 decibels or more, nor is the puretone threshold 30 decibels or less at 1000 Hz, and 70 decibels or more at 2000 Hz. Applying the results from the April 2016 VA audiological examination to Tables VI yields a Roman numeral value of II for the right ear and a Roman numeral value of III for the left ear. See 38 C.F.R. §§ 4.85, 4.86. Applying these values to Table VII, the Board finds that the Veteran’s hearing loss warrants a noncompensable evaluation. The tables referred to above were provided to the Veteran in the Statement of the Case dated in August 2016. Accordingly, the Board finds that the preponderance of the evidence is against entitlement to a compensable disability rating for bilateral sensorineural hearing loss. 38 C.F.R. § 4.3. Significantly, the April 2016 VA audiological examination shows that the Veteran’s hearing loss warrants a noncompensable evaluation. In addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak v. Nicholson, 21 Vet. App. 447 (2007). Such functional impairment has been appropriately considered but the overall evidence, as previously discussed, fails to support assignment of a compensable disability rating. Specifically, a review of the April 2016 VA audiological examination reflects that the examiner (an audiologist) found that there were functional effects of the Veteran’s hearing loss, noting that the Veteran’s hearing loss did not impact ordinary conditions of daily life, including his ability to work. While the Veteran understandably has problems hearing, the rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. Hence, the rating criteria contemplate the Veteran’s symptomatology. REASONS FOR REMAND With regard to the left knee issue, the Veteran was last afforded a VA examination for this disability in June 2014. While the June 2014 VA examination shows range of motion findings for both knees, it does not indicate whether the findings were on both active and passive motion and/or in weight-bearing and nonweight-bearing. Since this examination, a new precedential opinion that directly affects this case was issued by the United States Court of Appeals for Veterans Claims (Court). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Unfortunately, the June 2014 VA examination report does not comply with Correia. Accordingly, the Veteran must be afforded a new VA examination to correct the deficiencies noted above. Also, given the need to remand for other reasons all outstanding VA treatment records dated since June 2016 should be obtained on remand. The matter is REMANDED for the following action: 1. Obtain all outstanding VA treatment records dated from June 2016 to the present. 2. Arrange for the Veteran to undergo a VA examination for evaluation of his left knee disability. The examiner should test the range of motion (using a goniometer) in active motion, passive motion, weight-bearing, and nonweight-bearing, for the joints in question in accordance with Correia v. McDonald, 28 Vet. App. 158 (2016). If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. 3. Readjudicate the appeal. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD April Maddox, Counsel