Citation Nr: 18150612 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 16-15 462 DATE: November 15, 2018 ORDER The petition to reopen the claim of entitlement to service connection for hypertension is granted; the appeal is granted to this extent only. The claim of entitlement to service connection for angina is denied. The claim of entitlement to service connection for hypertension is denied. The claim of entitlement to service connection for a renal disability, to include Stage III chronic kidney disease, is denied. REMANDED The claim of entitlement to service connection for a cervical spine disability, to include degenerative disc disease, is remanded. The claim of entitlement to service connection for left arm numbness is remanded. The claim of entitlement to a disability rating in excess of 20 percent for post-operative residuals of a left acromioclavicular joint separation with osteoarthritis, is remanded. The claim of entitlement to a compensable disability rating for scars associated with post-operative residuals of a left acromioclavicular joint separation with osteoarthritis, is remanded. The claim of entitlement to a disability rating in excess of 50 percent for depression is remanded. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), is remanded. FINDINGS OF FACT 1. In July 1990, the RO denied service connection for the Veteran’s hypertension. The Veteran was notified of his rights but did not file a timely substantive appeal. 2. The Veteran’s service treatment records, in existence at the time of the July 1990 rating decision, were associated with the file subsequent to the July 1990 rating decision. 3. The Veteran’s angina did not occur in-service, did not present itself within one year after service, was not the proximate result of an in-service event, illness, or injury, and was not the proximate result of any service-connected disability. 4. The Veteran’s hypertension did not present itself during service or within one year after separation from service. 5. The Veteran’s renal disability did not occur in-service, did not present itself within one year after service, was not the proximate result of an in-service event, illness, or injury, and was not the proximate result of any service-connected disability. CONCLUSIONS OF LAW 1. The July 1990 rating decision denying the claim of service connection for hypertension is final. 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2018). 2. Relevant service department records existed at the time of the July 1990 rating decision, that were not associated with the claims file at the time of the July 1990 rating decision, subsequently became associated with the claims file. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). 3. The criteria for service connection for angina have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 4. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 5. The criteria for service connection for a renal disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Navy from May 1982 to June 1986. The Veteran served during Peacetime. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a June 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, and an April 2013 rating decision from the VA RO in St. Petersburg, Florida, in which jurisdiction of the file currently resides. With respect to a total disability rating based on individual unemployability (TDIU), the Veteran has appealed for higher schedular ratings for residuals of his left shoulder acromioclavicular joint separation, including osteoarthritis, scars of his left upper extremity, and depression, and he has alleged interference with his employment due to his service-connected disabilities in his June 2016 correspondence with the VA. Thus, a claim for TDIU exists. Rice v. Shinseki, 22 Vet. App. 447 (2009) (if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether TDIU is warranted). In this case, the Veteran has raised the question of unemployability. The Board has therefore added a TDIU claim to the title page to reflect the Board's jurisdiction over this matter. Further development is needed to properly adjudicate the TDIU claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered). In any case involving a finally denied claim, the Board must address whether new and material evidence has been received to reopen before addressing the merits of the claim, regardless of whether or not the agency of original jurisdiction (AOJ) has already addressed the question. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Wakeford v. Brown, 8 Vet. App. 237, 239-240 (1995). The Board notes that there were additional medical records received after the last statements of the case in March 2016. However, the evidence received is not relevant to any issue in the decision below. Thus, a waiver is not necessary, and this matter is properly before the Board. The issues of service connection for a cervical spine disability, service connection for left upper extremity numbness, an increased disability rating for residuals of a left shoulder acromioclavicular joint separation, to include osteoarthritis, an increased disability rating for scars associated with a left shoulder acromioclavicular separation, an increased disability rating for depression, and TDIU, on appeal, are REMANDED to the AOJ. VA will notify the Veteran if further action is required. VA has a duty to notify and assist the Veteran in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). New and Material Evidence 1. Whether new and material evidence has been received sufficient to reopen a claim for entitlement to service connection for hypertension Governing regulations provide that an appeal consists of a timely notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200 (2018). Rating actions from which an appeal is not timely perfected become final. 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. § 20.1103 (2018). Under 38 U.S.C. § 5108 (2012), VA may reopen a previously and finally disallowed claim when “new and material” evidence is presented or secured with respect to that claim. The provisions of 38 U.S.C. § 5108 (2012) require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-283 (1996). New and material evidence is not required to reopen a claim when, at any time after VA issues a decision on a claim, VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim. 38 C.F.R. § 3.156(c) (2018). Relevant records are those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate the Veteran’s claim. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). The Board notes that the Veteran was denied service connection for hypertension in a July 1990 rating decision. The Veteran was notified of this decision, including his appellate rights, in July 1990. However, he did not timely file a notice of disagreement regarding the claim for service connection for hypertension, and the July 1990 rating decision became final. 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. § 20.1103 (2018). The Board notes, however, that the Veteran’s service treatment records were associated with the claims file in July 2014, after the January 2012 claim for entitlement to service connection for hypertension. If VA receives relevant service department records that existed at the time of the prior denial but were not associated with the claims file, then VA will reconsider the claim de novo. 38 C.F.R. § 3.156(c) (2018). The Veteran separated from service in June 1986. Therefore, his service treatment records were in existence at the time of the July 1990 denial. However, the Veteran’s service treatment records were not associated with the file until July 2014, after the July 1990 decision. As such, the Board finds that new and material evidence is not needed to reopen the claim for entitlement to service connection for hypertension, and VA will reconsider this claim de novo. Id. Service Connection Service connection is warranted where the evidence of record established that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if preexisting, such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2018). Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2018). “To establish a right to compensation for a present disability, a veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’ – the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309(a) (2018). Presumptive service connection can be established based upon continuity of symptomatology for those chronic diseases set forth in 38 C.F.R. § 3.309(a). 38 C.F.R. §§ 3.307(a)(2)-(3), 3.309(a) (2018); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a veteran has served for 90 days or more during a period of war, or during peacetime service after January 1, 1947, and a chronic disorder becomes manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2018). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303 (2018). A Veteran can receive compensation via secondary service connection. Service connection may be secondarily established when a disability is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2018). 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) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). With all claims for service connection, in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board must assess the credibility and weight of all of the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue.”). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (2012); Gilbert, 1 Vet. App. at 49. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2018). The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). 2. Entitlement to service connection for angina The Board first turns its attention to the Veteran’s claim for service connection for angina. The Veteran’s service treatment records are silent for chest pain, and his June 1986 separation physical noted that the Veteran’s cardiovascular system was normal. The first evidence of angina is in a VA medical record in July 2005. The Veteran reported that he had coronary artery disease and angina. This diagnosis, however, was made by history only. In December 2011, the Veteran was seen by the VA nephrologist, who noted that the Veteran had diastolic dysfunction, with an ejection fraction of 60 percent. The medical documentation went on to note left ventricular relaxation noted in February 2010. In January 2012, the Veteran told a VA provider that he had occasional chest pain. He stated that his chest pain was not radiating and was not related to exertion or shortness of breath. He stated that it lasted for a few minutes and then resolved. The Veteran underwent a cardiac study in November 2015 due to chest pain and an abnormal electrocardiogram. The results of the study were a sinus rhythm with minimal ST depression and T-wave inversion. The report found that, given baseline findings, there was no further ST depression suggestive of ischemia. A myocardial infusion study found that the Veteran had a left ventricular ejection fraction of 80 percent and no left ventricular dilation. The Veteran claims entitlement to service connection for angina. However, as outlined above, a preponderance of the evidence is against this claim. The Veteran underwent a cardiac study in November 2015 due to complaints of chest pain and an abnormal electrocardiogram. As such, the Board finds that the first Holton element has been met. However, a preponderance of the evidence is against finding an in-service event, injury, or illness, the second Holton element. Notably, the Veteran’s service treatment records are silent for mention of chest pain. Moreover, the first specific mention of chest pain is in July 2005, 19 years after the Veteran’s separation from active service. Moreover, the Veteran does not contend that his angina began in-service, nor does he contend that it is causally related to an in-service event, illness, or injury. As a preponderance of the evidence is against finding an in-service event, the Veteran’s angina may not be service connected via direct service connection. 38 C.F.R. § 3.303 (2018); Holton, 557 F.3d at 1366. The Board has also considered presumptive service connection of the Veteran’s angina. 38 C.F.R. §§ 3.307, 3.309(a) (2018). Angina, however, is not a condition considered for presumptive service connection pursuant to 3.309(a). Therefore, the Veteran’s angina may not be granted service connection via presumptive service connection. Id. The Veteran, in his January 2012 claim, asserted that his angina was secondary to hypertension. While the Veteran may receive service connection if a disability is proximately caused by an already service-connected disability, as addressed in the analysis below, the Veteran’s hypertension is not a service-connected disability. 38 C.F.R. §§ 3.310(a)-(b) (2018). As such, the Veteran’s angina may not be granted service connection via secondary service connection. The Board notes that the Veteran has not been afforded a VA examination to determine the etiology of his angina. The VA must provide an examination when the evidence shows: (1) A current disability; (2) an in-service event, injury, or disease; (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for the VA to make a decision. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board has considered the McLendon elements regarding his angina diagnosis. While he has a current disability of angina, as noted above, a preponderance of the evidence is against finding the existence of an in-service event or incident, the second McLendon element. As such, the Board finds that a VA examination is not required and VA’s duty to assist has been met in this regard. The Board has considered the evidence of record and affords the greatest probative weight to the medical evidence of record, which demonstrates that the Veteran did not demonstrate angina until greater than one year after discharge. The medical documentation was procured by licensed medical professionals, making them competent to obtain and interpret these measurements and there is no evidence that these professionals were not credible. Moreover, these professionals assessed the Veteran in person with appropriate measures. As such, the Board affords these measures great probative weight. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-57; 38 C.F.R. § 3.102 (2018). For these reasons, the claim is denied. 3. Entitlement to service connection for hypertension The Board next turns its attention to the Veteran’s claim for service connection for hypertension. For VA rating purposes, “hypertension” means that diastolic blood pressure is predominately 90 mm. or greater; “isolated systolic hypertension” means that the systolic blood pressure is predominately 160 mm. or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2018). The Veteran’s service treatment records are silent for blood pressure measurements consistent with hypertension. Private medical records, dated during the Veteran’s service, demonstrate blood pressure readings below the threshold for hypertension. See Private Treatment Records, dated July 1985, November 1984. A private medical center visit in June 1987 revealed blood pressure below the threshold for hypertension. A blood pressure measurement taken by a private provider in March 1988 demonstrated a blood pressure measurement of 150/90. Blood pressure measurements during a March 1989 emergency room visit measured at 170/110. In June 1989, the Veteran was seen by a VA provider. He was seen with a history of hypertension and the provider ordered a chest x-ray to rule out cardiomegaly. His blood pressure measured 140/90, when taken by a private provider in December 1989, a visit associated with an ankle injury. The Veteran continued to report and seek treatment for hypertension after the June 1989 VA medical center visit. See VA Treatment Records, dated January 2012, December 2011, September 2007, July 2005, May 2001. The Board has considered the elements for direct service connection regarding the Veteran’s hypertension. The Veteran has a current diagnosis of hypertension. As such, the Board finds that the first Holton element is met. However, the Board finds that a preponderance of the evidence is against finding an in-service event, illness, or injury. Notably, the Veteran’s blood pressure measurements taken during service, in both service treatment records and private treatment records, revealed readings below the threshold of hypertension, pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. As such, the Board finds that the second Holton element is not met, and the Veteran may not be awarded service connection for hypertension via direct service connection. 38 C.F.R. § 3.303 (2018); Holton, 557 F.3d at 1366. The Board has also considered presumptive service connection regarding the Veteran’s hypertension. While hypertension is a chronic disease contemplated by 38 C.F.R. § 3.309(a), the Veteran’s first incident of a blood pressure reading meeting the VA threshold for hypertension was in March 1988, greater than one year after the Veteran’s separation from the Navy. 38 C.F.R. § 3.307 (2018). As such, the Veteran may not be awarded service connection for hypertension via presumptive service connection. 38 C.F.R. §§ 3.307, 3.309(a) (2018). The Board notes that the Veteran has not been afforded a VA examination to determine the etiology of his hypertension. The VA must provide an examination when the evidence shows: (1) A current disability; (2) an in-service event, injury, or disease; (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for the VA to make a decision. See McLendon, 20 Vet. App. at 79. The Board has considered the McLendon elements regarding his hypertension diagnosis. While he has a current disability of hypertension, as noted above, a preponderance of the evidence is against finding the existence of an in-service event or incident, the second McLendon element. As such, the Board finds that a VA examination is not required and VA’s duty to assist has been met in this regard. The Board has considered the evidence of record and affords the greatest probative weight to the medical evidence of record, which demonstrates that the Veteran did not demonstrate blood pressure measurements consistent with hypertension until greater than one year after discharge. The measurements were taken by licensed medical professionals, making them competent to obtain and interpret these measurements and there is no evidence that these professionals were not credible. Moreover, these professionals assessed the Veteran in person with appropriate measures. As such, the Board affords these medical records great probative weight. The Board has considered the Veteran’s statement to a VA provider in July 2005 that he has had hypertension since he was in the military. While the Veteran is competent to attest to symptomatology observable to the senses, there is no evidence that he has the requisite medical expertise to determine his blood pressure readings. See Jandreau, 492 F.3d at 1376-1377. Moreover, while the Board does not doubt the Veteran’s credibility regarding his perception of his symptoms, his impressions are inconsistent with the evidence of record regarding his blood pressure during his time in the Navy. As such, the Board affords the Veteran’s statements no probative weight. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b) (2012); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-57; 38 C.F.R. § 3.102 (2018). For these reasons, the claim is denied. 4. Entitlement to service connection for a renal disability, to include Stage III Chronic Kidney Disease The Board next turns its attention to the Veteran’s claim for entitlement to service connection for a renal disability, to include Stage III Chronic Kidney Disease. The Veteran’s service treatment records are silent for any renal disease or symptoms thereof. The first evidence of kidney dysfunction comes in the form of an elevated creatinine level in June 2005. The Veteran’s September 2007 VA records revealed a diagnosis of chronic kidney disease with a six-millimeter cystic structure on the left kidney. The Veteran was seen in September 2009 at the VA, where the Veteran’s chronic kidney disease demonstrated slowly increasing proteinuria. The provider opined that the Veteran’s chronic kidney disease was “most likely” related to hypertension or hyperlipidemia. The Veteran continued to be treated by VA nephrologists for chronic kidney disease throughout the period on appeal. See VA Treatment Records, dated March 2013, January 2012, December 2011, September 2011. The Veteran claims entitlement to service connection for a renal disorder, including stage III chronic kidney disease. A preponderance of the evidence, however, is against this claim. The Board has considered the elements of direct service connection for chronic kidney disease. The Veteran has a diagnosis of stage III chronic kidney disease, as noted in the January 2012 VA treatment records. As such, the Board finds that the first Holton element is met. However, a preponderance of the evidence is against the finding of an in-service event, illness, or injury. Notably, there is no evidence of renal disease, or any symptoms thereof, within the Veteran’s service treatment records, or private treatment records relevant to the Veteran’s dates of active service. Moreover, the Veteran does not contend that his renal disability began in-service, nor does he contend that it is directly, causally related to an in-service event, illness, or injury. As such, the Board finds that the second Holton element, an in-service event, illness, or injury, is not met. As the second Holton element is not met, the Veteran may not be afforded service connection via direct service connection. 38 C.F.R. § 3.303 (2018); Holton, 557 F.3d at 1366. The Board has also considered the possibility of service connection via presumptive service connection. 38 C.F.R. §§ 3.307, 3.309 (2018). Although cardiovascular-renal disease is a chronic disease contemplated by 38 C.F.R. § 3.309(a), the Veteran’s renal disease did not present itself until 2005, 19 years after his separation from the Navy. As such, his renal disability did not present within the requisite one year after separation, pursuant to 38 C.F.R. § 3.307. As such, the Veteran’s renal disability may not be service connected via presumptive service connection. Id. The Veteran specifically claims that his renal disability should be afforded secondary service connection, as it was caused by his hypertension. The Board notes that the evidence is not inconsistent with the Veteran’s assertion that his renal disability is due to his hypertension. Notably, a September 2009 VA treatment record states that his chronic kidney disease is, likely, due to hypertension or hyperlipidemia. The Board notes, however, that the Veteran’s hypertension is not a service-connected disability, as analyzed in detail above. To be afforded secondary service connection, the Veteran’s disability must be proximately caused, or aggravated, by an already service-connected disability. As the Veteran’s hypertension is not a service-connected disability, his renal disability may not be awarded service connection via secondary service connection. 38 C.F.R. §§ 3.310(a)-(b) (2018). The Board notes that the Veteran has not been afforded a VA examination to determine the etiology of his renal disability. The VA must provide an examination when the evidence shows: (1) A current disability; (2) an in-service event, injury, or disease; (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for the VA to make a decision. See McLendon, 20 Vet. App. at 79. The Board has considered the McLendon elements regarding his renal disability. While he has a current disability of stage III chronic kidney disease, as noted above, a preponderance of the evidence is against finding the existence of an in-service event or incident, the second McLendon element. As such, the Board finds that a VA examination is not required and VA’s duty to assist has been met in this regard. The Board has considered the evidence of record and affords the greatest probative weight to the medical evidence of record, which reveals that the Veteran did not demonstrate evidence of chronic kidney disease until greater than one year after discharge. The measurements were taken by licensed medical professionals, making them competent to obtain and interpret testing and there is no evidence that these professionals were not credible. Moreover, these professionals assessed the Veteran in person with appropriate measures. As such, the Board affords these records great probative weight. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b) (2012); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-57; 38 C.F.R. § 3.102 (2018). For these reasons, the claim is denied. REASONS FOR REMAND The VA must provide an examination when the evidence shows: (1) A current disability; (2) an in-service event, injury, or disease; (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for the VA to make a decision. See McLendon, 20 Vet. App. at 79. Once VA decides that it is appropriate to provide a VA examination, it must be an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 1. Entitlement to service connection for a cervical spine disability, to include degenerative disc disease, is remanded. The Board notes that the Veteran received a VA examination to determine the etiology of his cervical spine disability in March 2012. However, this examination was not adequate, as it did not address the etiology of the Veteran’s cervical spine disability. The Veteran underwent a subsequent VA examination in March 2013. The examiner found it was less likely than not that the Veteran’s cervical spine disability was incurred in or caused by an in-service injury. The examiner stated that there was no evidence that the Veteran had a chronic cervical spine condition during service and there was no evidence of such a disability for 26 years after separation. The examiner further stated that the degenerative disc disease was part and parcel of the natural aging process and was influenced by age, genetics, and axial loading. An addendum opinion, not based upon an in-person examination, was offered three years later, in March 2016. This VA examiner opined that the Veteran’s degenerative disc disease was not aggravated by the Veteran’s left shoulder disability. The examiner stated that the spine and the acromioclavicular joint were geographically separate so as to not allow systemic influence and it was more likely a cumulative effect of wear and tear over many years as compared to anatomically unrelated post-operative residuals. The Board finds these opinions inadequate. The March 2013 examination opined that the Veteran’s cervical spine disability first presented itself 26 years after separation from service. However, service treatment records demonstrate the Veteran complained of “irritation” to the left side of his neck in August 1985, prior to separation from service, and he complained, again, in January 2010, less than the reported 26 years after separation from the Navy. Moreover, the March 2013 examination did not address the statement of a March 2012 VA examiner, opining upon the etiology of a peripheral nerve disorder, that specifically asserted that the Veteran’s spinal cord disability could have been incurred in the same accident that caused the injury to his service-connected left shoulder. To be considered adequate, an examination should consider all of the evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295. The Board also notes that the examiner stated that the Veteran’s cervical spine disability had not progressed beyond a natural progression of the disease, but offered no explanation. A merely conclusory statement is inadequate in offering an opinion of etiology of a disability. Stefl v. Nicholson, 21 Vet. App. 120 (2007). In light of the above, the Board finds that this issue must be remanded to obtain a new VA examination. 2. Entitlement to service connection for left arm numbness is remanded. The Veteran received a VA examination in March 2012 to determine the etiology of his left upper extremity numbness. The examiner found no existence of a peripheral nerve condition or peripheral neuropathy. However, the examiner noted that the Veteran’s cervical magnetic resonance imaging scan revealed what may have been a small syrinx within the spinal cord at the C7 vertebral level, which, the examiner opined, may explain the Veteran’s left finger numbness. The examiner further stated that the Veteran’s cervical cord trauma may have been sustained at the same time as he sustained his left shoulder injury. As the examiner opined that the Veteran’s left upper extremity numbness could have originated from the Veteran’s spinal cord, and the Veteran’s left upper extremity numbness coincided with both left shoulder and cervical spine complaints, the Board finds that the issues of entitlement to service connection for a cervical spine disability and left upper extremity numbness are inextricably intertwined. See VA Treatment Records, dated August 2011, August 2010, September 2009. Therefore, a final decision on the issue of entitlement to service connection for left upper extremity numbness cannot be rendered at this time and must be remanded for contemporaneous adjudication. See Harris, 1 Vet. App. at 180. 3. Entitlement to a disability rating in excess of 20 percent for post-operative residuals of a left acromioclavicular joint separation with osteoarthritis, is remanded. The Board notes that the Veteran was last afforded a VA examination to assess the severity of his left shoulder disability in March 2012. Since that examination, the record reflects that the Veteran’s disability may have increased in severity. Specifically, the Veteran reported to a VA treatment provider in March 2013 that his partner was required to clean, carry bags, help him bathe, and help him dress, due to his pain. The evidence of record, therefore, supports a possible worsening of the Veteran’s left shoulder and its symptomatology. The Board notes that a new examination is appropriate when there is an assertion of an increase in severity since the last examination. Therefore, the Veteran should be afforded another examination on remand. See 38 C.F.R. § 3.159 (2018); see also Barr, 21 Vet. App. at 312; Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995). 4. Entitlement to a compensable disability rating for scars associated with post-operative residuals of a left acromioclavicular joint separation with osteoarthritis, is remanded. The Board notes that the Veteran was last afforded a VA examination to assess the severity of his shoulder, in which his scar was assessed, in March 2012. Since that examination, the record reflects that the Veteran’s left shoulder, and resulting scar, may have increased in severity. Specifically, the Veteran reported to a VA treatment provider in March 2013 that his partner was required to clean, carry bags, help him bathe, and help him dress, due to his pain. The Veteran did not specify whether his shoulder, or scar, or both were the cause of the pain. As the March 2012 VA examination did not find that the Veteran’s left shoulder scar was either painful or unstable, the Board finds that, in considering of the evidence in light most favorable to the Veteran, the evidence of record supports a possible worsening of the Veteran’s left shoulder scar and its symptomatology. The Board notes that a new examination is appropriate when there is an assertion of an increase in severity since the last examination. Therefore, the Veteran should be afforded another examination on remand. See 38 C.F.R. § 3.159 (2018); see also Barr, 21 Vet. App. at 312; Palczewski, 21 Vet. App. at 181; Snuffer, 10 Vet. App. at 403; VAOPGCPREC 11-95 (1995). 5. Entitlement to a disability rating in excess of 50 percent for depression is remanded. The Board notes that the Veteran was last afforded a VA examination to assess the severity of his depression in May 2012. Since that examination, the record reflects that the Veteran’s depression may have increased in severity. Specifically, the Veteran submitted a May 2016 private provider disability benefits questionnaire that asserted that the Veteran demonstrated social and occupational deficits in most areas and that he struggled remembering basic information. Prior VA treatment notes, however, indicated appropriate affect, logical and goal-directed thought processes, and grossly intact memory. See VA Treatment, dated March 2013. As such, the private disability benefits questionnaire, alone, is not sufficient to adjudicate the claim for an increased disability rating for the Veteran’s depression. The Board notes that a new examination is appropriate when there is an assertion of an increase in severity since the last examination. Therefore, the Veteran should be afforded another examination on remand. See 38 C.F.R. § 3.159 (2018); see also Barr, 21 Vet. App. at 312; Palczewski, 21 Vet. App. at 181; Snuffer, 10 Vet. App. at 403; VAOPGCPREC 11-95 (1995). 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), is remanded. The Board finds that the claims for service connection for a cervical spine disability, service connection for left upper extremity numbness, an increased disability rating for depression, an increased disability rating for the left shoulder disability, an increased disability rating for the left shoulder scar, and the claim of entitlement to TDIU are inextricably intertwined. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2018). The aforementioned claims, currently on remand, are “intertwined” because a decision on the claims for service connection for a cervical spine disability, service connection for left upper extremity numbness, an increased disability rating for depression, an increased disability rating for the left shoulder disability, and an increased disability rating for the left shoulder scar will impact the claim for TDIU. Consequently, the aforementioned claims on remand and the claim of entitlement to TDIU must be remanded for contemporaneous adjudication. See Harris, 1 Vet. App. at 180. The matters are REMANDED for the following action: 1. Appropriate efforts should be made to obtain and associate with this case file any outstanding VA medical records and any outstanding private treatment records, with all necessary assistance from the Veteran. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 2. Obtain a VA examination before a physician with the appropriate training and expertise for the Veteran's cervical spine and neurological symptoms associated with the Veteran’s left upper extremity. The electronic claims file must be made available to and reviewed by the examiner, and a note that it was reviewed should be included in the report. After reviewing the claims file and examining the Veteran, the examiner should answer the following questions: (a.) Is it as likely as not (a fifty percent probability or greater) that the Veteran's cervical spine disability, to include cervical spine degenerative disc disease, was caused by the Veteran's active service, to include the reported 1985 motor vehicle accident? (b.) Identify any neurological symptoms of the Veteran’s left upper extremity. (c.) Is it as likely as not (a fifty percent probability or greater) that the Veteran’s left upper extremity neurological symptoms were caused by the Veteran’s active service, to include the reported 1985 motor vehicle accident? (d.) Is it as likely as not (a fifty percent probability or greater) that the Veteran’s left upper extremity neurological symptoms were caused or aggravated by the Veteran’s service-connected left shoulder disability? (e.) Is it as likely as not (a fifty percent probability or greater) that the Veteran’s left upper extremity neurological symptoms were caused or aggravated by the Veteran’s cervical spine disability? A complete rationale is to be provided for any and all opinions offered. It should be noted that the Veteran is competent to attest to observable symptomatology. The examiner's attention is invited to the Veteran's statements concerning the onset of his claimed disability. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not take into account the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Jones, 23 Vet. App. at 382. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 3. The Veteran should also be scheduled for a VA examination before an appropriate physician to determine the current nature and severity of his service-connected left shoulder disability, including an assessment of the characteristics of the Veteran’s left shoulder post-operative scar. The examiner should review the claims file and should perform all appropriate tests and diagnostics, including range of motion testing and neurological evaluation. All pertinent symptomatology and findings must be reported in detail. The examiner is asked to report the range of motion measurements in degrees. Range of motion should be tested actively and passively, in weight bearing, and after repetitive use. The examiner should consider whether there is likely to be additional range of motion loss due to any of the following: (1) during flare-ups; and, (2) as a result of pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. The examiner is also asked to report the characteristics and symptomatology associated with the Veteran’s service-connected left shoulder scar, including, but not exclusive of, size, stability, and pain. 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. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any would allow for a more definitive opinion. 4. Schedule the Veteran for a VA examination to determine the current nature and severity of his depression. The examiner must review the entire claims file, including a copy of this remand. Review of these documents should be noted in the claims file. The examiner should opine as to the present severity of the Veteran's depression, as well as provide an assessment of the functional impairment attributed to this disability. The examiner must provide all findings, along with a complete rationale for his or her opinion in the examination report. If any opinion provided cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. The examiner should also identify what additional information or evidence (if any) may allow for a more definitive opinion. (Continued on the Next Page) 5. Thereafter, readjudicate all of the issues on appeal, to include TDIU. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. E. Trotter, Associate Counsel