Citation Nr: 18151842 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-10 810 DATE: November 20, 2018 ORDER The claim of entitlement to service connection for a low back disorder is reopened. The claim of entitlement to service connection for a bilateral knee disorder is reopened. Entitlement to an evaluation higher than 70 percent, for service connected unspecified bipolar disorder and unspecified anxiety disorder, formerly rated as mood disorder, is denied. REMANDED Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for a bilateral knee disorder is remanded. Entitlement to an increased evaluation higher than 20 percent for a left shoulder strain is remanded. Entitlement to a total disability evaluation based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. An April 1999 rating decision denied entitlement to service connection for a low back disorder and a bilateral knee disorder. The Veteran did not appeal, and did not submit new and material evidence within one year. 2. A February 2010 rating decision denied entitlement to service connection for a low back disorder and bilateral knee disorder. The Veteran did not appeal, and did not submit new and material evidence within one year. 3. The evidence associated with the file after the February 2010 rating decision includes evidence that relates to an unestablished fact necessary to substantiate the claim, is neither cumulative nor redundant of evidence already of record, and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a low back disorder. 4. Throughout the period on appeal, the Veteran’s unspecified bipolar disorder and unspecified anxiety disorder did not approximate total social and occupational impairment. CONCLUSIONS OF LAW 1. New and material evidence has been received sufficient to reopen a claim of entitlement to service connection for a low back disorder. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2018). 2. New and material evidence has been received sufficient to reopen a claim of entitlement to service connection for a bilateral knee disorder. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2018). 3. The criteria for entitlement to an evaluation higher than 70 percent for service-connected unspecified bipolar disorder and unspecified anxiety disorder are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130 Diagnostic Code (DC) 9435 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the Army from November 1995 to October 1998 and subsequently from May 2003 to May 2009. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Chicago, Illinois. In his March 2016 substantive appeal the Veteran declined Board hearing before a Veterans Law Judge (VLJ). In January 2018 the Veteran filed an application for increase based on unemployability. In light of the Veteran’s contentions, the issue of TDIU is raised by the record and is properly before the Board. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009) (noting that a claim for a TDIU rating is part of an increased rating claim when such claim is raised by the record). The issues of entitlement to service connection for a low back disorder, a bilateral knee disorder, entitlement to an increased evaluation for left shoulder strain, and TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). Duties to Notify and Assist Neither the Veteran nor his attorney has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Claim to Reopen In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.1100, 20.1103. A finally disallowed claim, however, may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108. Regardless of the action taken by the RO, the Board must determine whether new and material evidence has been received subsequent to an unappealed RO denial. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). As part of this review, the Board considers evidence of record at the time of the previous final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim, and evidence submitted since a prior final disallowance. Evans v. Brown, 9 Vet. App. 273, 285-86 (1996). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist or consideration of a new theory of entitlement. Shade, 24 Vet. App. at 117-18. Additionally, new and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Furthermore, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed but were not associated with the claims file when VA first decided the claim, VA will reconsider the claim, rather than requiring new and material evidence. 38 C.F.R. § 3.156(c)(1). A claim is not reconsidered, however, where VA could not have obtained the records when it initially decided the claim because the records did not exist at that time, or because the claimant failed to provide sufficient information to identify and obtain the records from the respective service department, the Joint Services Records Research Center, or any other official source. 38 C.F.R. § 3.156(c)(2). To establish service connection, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called nexus requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). In an April 1999 rating decision, the RO denied service connection for a low back disorder because there was no evidence of a current disability or evidence that the disorder was caused by service. The Veteran did not appeal that decision nor submit new and material evidence within one year. The rating decision is thus final based on the evidence then of record. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. In an April 1999 rating decision, the RO denied service connection for a bilateral knee disorder because there was no evidence of a current disability, in-service incurrence, or that the disorder was caused by service. The Veteran did not appeal that decision nor submit new and material evidence within one year. The rating decision is thus final based on the evidence then of record. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. In a February 2010 rating decision, the RO denied service connection for a low back disorder because there was no current disability or evidence a disorder was cause by service. The Veteran did not appeal that decision nor submit new and material evidence within one year. The rating decision is thus final based on the evidence then of record. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. In a February 2010 rating decision, the RO denied service connection for a bilateral knee disorder because there was no current disability, no evidence of in-service incurrence or evidence a disorder was caused by service. The Veteran did not appeal that decision nor submit new and material evidence within one year. The rating decision is thus final based on the evidence then of record. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Evidence of record at the time of the February 2010 rating decision included service treatment records (STRs), service personnel records (SPRs), a November 2009 VA examination, VA treatment records, lay statements, and private treatment records. Those STRs did not indicate an in-service, injury, event or incurrence for a bilateral knee disorder. The November 2009 VA examination showed an essentially normal bilateral knee examination with pain consistent with mild patellofemoral knee strain. The VA treatment records and private treatment records did not indicate a current diagnosis for a low back disorder. The November 2009 VA examination showed a normal lumber spine and no neurological deficits. Evidence submitted after the February 2010 rating decision includes the following: 1) lay statements, 2) buddy statements, and 3) VA treatment records. The November 2013 buddy statement demonstrated the Veteran could not participate in physical training activities during service due to back and knee pain. In a November 2015 report of information, the RO confirmed the Veteran and the fellow service member served together from July 2003 to July 2004. The VA treatment records showed active medication for knee and back pain. Additionally, VA treatment records indicated worsening knee and back pain. In an April 2013 lay statement, the Veteran indicated his knee and back pain cause difficulty in standing and using stairs. The Board finds that new and material evidence has been presented. The evidence, including a lay statement, buddy statement, and VA treatment records are new because it was not previously submitted to VA. The evidence is material because it relates to unestablished facts necessary to establish the claim -evidence of a current disability for a low back disorder and bilateral knee disorder. See 38 C.F.R. § 3.303(a); Shedden, 381 F.3d at 1167. Additionally, the evidence is neither cumulative nor redundant as that evidence was not of record at the time of the prior denial. See 38 C.F.R. § 3.156(a). Further, new evidence is to be presumed credible for purposes of deciding whether a previously denied claim may be reopened. Justus, 3 Vet. App. at 513. Moreover, when considering the new evidence in conjunction with the evidence already of record, combined with VA assistance including an examination, it raises a reasonable possibility of substantiating the claim. Shade, 24 Vet. App. at 117. Accordingly, for all of the above reasons, the Veteran’s claims are reopened. Increased Evaluation Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. The Veteran’s service connected unspecified bipolar disorder and unspecified anxiety disorder is rated under 38 C.F.R § 4.130, DC 9435. Under the General Rating Formula for Mental Disorders, the Veteran’s current 70 percent evaluation contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for a mental disorder when there is total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, DC 9435. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms; the length of remissions; and the veteran’s capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126 (a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). “[A] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The symptoms shall have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio, 713 F.3d 112. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126. In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126. The Veteran filed a claim for increase in September 2012. The Board has addressed various treatment records below, but not all records. In a November 2011 VA record, the Veteran reported his mood was up and down and described irritability, anger, and occasional mild anxiety. The Veteran reported decreasing audio and visual hallucinations and had not experienced either for two to three weeks prior. In April 2012, VA treatment showed the Veteran experienced worsening insomnia, mild unease, mild irritability, low energy, and mild inability to feel pleasure. The Veteran stated he experienced symptoms for a couple of months. The Veteran reported a promotion at work. In an October 2012 VA treatment record, the Veteran reported feeling more anxious, edgy, and irritable over the last few months. The Veteran reported a verbal altercation with his girlfriend and felt she was very afraid of him. The Veteran expressed that his mood was affecting his ability to concentrate at work. The treatment provider noted the Veteran’s mood was anxious and guarded and recommended a change in medication. Later in the same month the Veteran reported for a follow-up. The Veteran reported symptoms of anxiety, insomnia, and panic attacks. The Veteran stated a few days prior he had a panic attack while driving and had to pull over. In a November 2012 VA record, the Veteran reported blurred vision and visual hallucinations which the treatment provider attributed to a change in medication. Later in November 2012, the Veteran reported symptoms of elevated mood, impulsive feelings (including just swerving into traffic to see what happens), racing thoughts, talking fast, feelings of special powers, and increased goal directed activities without sleep. The treatment provider determined the Veteran had mania and hypomania symptoms and ordered mood stabilizers to target those symptoms. January 2013 and May 2013 mental health VA treatment showed improved mood. VA treatment records showed the Veteran tested positive for cocaine March 2013. The Veteran expressed frustration that the lab made a mistake and was adamant that he did not use illicit drugs. In an April 2013 statement the Veteran noted that his mental health symptoms had worsened. The Veteran stated he had three failed marriages, no relationship with his children, and no friends. The Veteran also explained he had angry outburst at work. In a March 2013 statement, the Veteran’s co-worker stated they witnessed an angry outburst at work. In June 2013 the Veteran’s partner called and stated he has more mood swings, impulsive spending, and was doing well until three weeks prior. She expressed concern over whether the Veteran was taking his medication. Additionally, she felt the Veteran did not state what was on his mind during treatment. The Veteran reported the same day for mental health treatment. The Veteran reported he was doing a lot worse with symptoms of mood swings, anger, and impulsive spending. In July 2013 the Veteran checked in for his appointment but had a verbal altercation with another patient. The treating physician attempted to bring the Veteran back to the office but he Veteran refused and stated he would reschedule. The Veteran’s partner called and expressed the Veteran was very forgetful including forgetting events that have happened in the past. Additionally, she reported the Veteran’s emotions seemed very flat. The Veteran received a VA examination in July 2013. The Veteran reported anxiety interacting with people, but not when he was alone. He worked as a medical secretary and finds that it was stressful dealing with people. He reported daily passive suicidal ideations, but no active plan. He denied homicidal ideations. The examiner found the Veteran neatly dressed, alert and oriented, with normal speech, and fair insight and judgment. There was paranoia. The examiner found occupational and social impairment with deficiencies in most area, such as work, school, family relations, judgment, thinking, and mood. The examiner noted symptoms of: depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, mild memory loss, flattened affect difficulty understanding complex commands, disturbances or motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, impaired impulse control, and persistent delusions or hallucinations. The examiner noted the Veteran was in a two-year relationship and is able to communicate adequately at work. The examiner also noted the Veteran had not meaningful relationships or close friends. An August 2013 VA mental health treatment note showed the Veteran experienced poor memory, difficulty concentrating, auditory hallucinations, paranoia, mood swings, anger, and an inability to stay still. In a September 2013 VA record, the treatment provider noted worsening symptoms including: forgetfulness, irritability, impulsivity, distracted with racing thoughts, anger, and insomnia. The Veteran reported getting into fights with people on the street and co-workers, forgetting to take medications, and spending excessive amounts of money. The Veteran endorsed fleeting thoughts of suicidal ideation but no plan. The treatment provider noted the Veteran’s hypomania and depression symptoms were escalating and referred the Veteran to intensive group therapy. The Veteran regularly attended group therapy in September 2013. The Veteran stopped attending in October 2013 and did not complete the three-week program. The group treatment provider noted the Veteran increased his participation and showed less irritability during his time in group therapy. In December 2013 VA records, the Veteran reported unstable mood, irritability, racing thoughts, rapid speaking and anger. From February 2014 until September 2014 the Veteran missed several scheduled mental health appointments. A September 2014 record showed the Veteran reported ongoing auditory hallucinations, nightmares, decreased sleep, racing thoughts, and paranoia. The treatment provider noted the Veteran was uncooperative, had poor impulse control, poor insight and judgment, and left in the middle of the evaluation. The Veteran received a VA examination in October 2014. The Veteran reported moving in with his girlfriend but that he was not in touch with his family. He had no friends and voided people. The Veteran stated that random homicidal thoughts popped into his head and that he quit working due to irritability. He had gone back to school and was able to participate in group study and interacting with his professors. He reported suicidal ideations the week before and intermittent poor hygiene. The examiner found occupational and social impairment with deficiencies in most area, such as work, school, family relations, judgment, thinking, and mood. The Veteran reported he was in school full time for a Bachelor’s degree and getting good grades. The examiner noted symptoms of: depressed mood, anxiety, suspiciousness, panic attacks more than once a week, mild memory loss, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships. The examiner explained the Veteran’s mental health symptoms including: mood swings, irritability, anger, impulsivity, hallucination, and mild paranoia are mostly situational and not persistent. In December 2014, a VA mental health provider noted symptoms of anger, irritability, paranoia, auditory hallucinations, fair insight, and limited judgment. In April 2015, a VA mental health provider noted the Veteran was initially distant and irritable but was pleasant and cooperative by the end of the session. The Veteran reported occasional panic attacks. The treatment provider stated cognition was grossly intact and insight and judgment were fairly good. In June 2015 the Veteran reported experiencing symptoms of increased energy, racing thoughts, irritability, impulsiveness with spending, decreased sleep, and steady mood. The Veteran received VA treatment in August 2015, September 2015, November 2015, January 2016, and February 2016. The Veteran continually reported symptoms of irritability and mood fluctuations but consistently noted mood improvement with medication. A May 2016 VA mental health treatment note showed the Veteran experienced mood swings, irritability, and passive suicidal ideation. The Veteran noted a safety plan if he ever felt active suicidal ideation. The Veteran’s treating physician noted the issues of mood instability, irritability, anger management, and struggles with employment. The Veteran acknowledged graduating in April 2016 with a Bachelor of Science. The treating physician opined that the Veteran would be unable to obtain or maintain suitable employment due to his service connected disabilities. In a September 2016 VA record, the Veteran reported his mood is irritable or down and endorsed that occasionally he has an increase in energy and impulsivity. In October 2016, the Veteran reported that he broke up with his partner and was currently living with his mother. The Veteran stated he had a suicidal thought a month ago but no plan or intent. The Veteran endorsed visual hallucinations, paranoia, mood fluctuations, racing thoughts, increased energy, decreased need for sleep, and impulsivity. In a December 2016 VA record, the Veteran reported decreased motivation, sleep impairment, irritability, increased nightmares, increased flashbacks. The Veteran endorse occasionally suicidal ideation with no plan or intent. The treating physician discussed the suicidal ideation with the Veteran’s mother. She explained there are firearms in the house but that the Veteran does not have access to the firearms. The Veteran’s mother stated she would continue to monitor the Veteran and provide support. The Veteran received treatment in January 2017 and March 2017 and his symptoms remained unchanged. In May 2017, the Veteran reported more stable mood, less depression, less hypomania, improved sleep, less anxiety, and less irritability. The Veteran endorsed experiencing hypervigilance and avoidance. In October 2017 VA records, the Veteran reported increased irritability and passive suicidal ideation with no intent or plan. The Veteran stated he had thoughts of wishing he was dead. He endorsed experiencing periods mood with crying. In December 2017, the treatment provider noted hypomania including, increased energy, increase in goal directed activities, decreased sleep and increased irritability. The Veteran received mental health treatment in February 2018, April 2018, and July 2018. The Veteran report fair mood, feeling down, irritability, and anxiousness. In July 2018 the Veteran’s treatment provider noted decreased focus, concertation and memory but noted those fluctuate over time. The Veteran received a recent VA examination in October 2018. The Veteran reported living with his girlfriend and having no contact with his children. He had job for 2 months in 2017 but had to quit. He denied recent thoughts of harming himself. The examiner found the Veteran fully oriented with good insight and judgment. The examiner found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner reported the Veteran lives with his girlfriend and chooses not to maintain contact with his two grown children. The examiner noted symptoms of suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and impaired impulse control. The examiner noted the Veteran’s mood symptoms are chronic and have fluctuated depending on the nature of the symptoms in that cycling episode. The examiner determined current medication was helpful in stabilizing symptoms but noted mood instability, anger, aggression, and impulsivity have an ongoing negative impact on functioning. Based on a thorough review of the evidence of record, including the Veteran’s lay statements, the Board finds that the evidence of record reflects that the Veteran’s unspecified bipolar disorder and unspecified anxiety disorder symptoms during the entire claims period do not warrant an evaluation of 100 percent. The VA treatment records and VA examination reports demonstrate significant, but not total, social and occupational impairment. Although the Veteran avoids his children and other family members, he maintained a relationship with his girlfriend, was able to participate in small group study, and interacted with professors. Additionally, the VA examiners did not find grossly inappropriate behavior or persistent delusions or hallucinations, and consistently found the Veteran fully oriented. Further, although there were intermittent homicidal and suicidal ideations, they were not persistent. Moreover, the evidence demonstrated normal thought processes and speech. The Veteran did not report, and the evidence did not show, memory loss for own occupation or name. The Veteran did report intermittent poor hygiene, but did not report an inability to perform activities of daily living, and the VA examiners found the Veteran attentive ot hygiene. On review of the evidence of record, the Board finds that the symptoms, although significant, do not more nearly approximate the criteria for a 100 percent evaluation and are not of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d 112. Accordingly, a 100 percent evaluation is not for assignment. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Service Connection Remand is required to secure adequate examinations. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The central issue in determining probative value of a medical opinion is whether the examiner was informed of the relevant facts. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Where pain alone results in functional impairment of earning capacity, even if there is no identified underlying diagnosis, it can constitute a disability. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Veteran received a VA examination for a bilateral knee disorder in February 2016. In an April 2013 statement the Veteran reported he was taking pain medication for his back and knee pain. VA treatment records confirmed active pain medications for back and knee pain. The examiner found there was no current bilateral knee disorder without addressing a February 2010 VA examination that found pain consistent with mild patellofemoral knee strain and without addressing whether there was objective evidence of pain alone that results in functional impairment of earning capacity. Remand is thus required. The Veteran received a VA examination for a low back disorder in February 2016. In an April 2013 statement the Veteran reported he was taking pain medication for his back and knee pain. VA treatment records confirmed active pain medications for back and knee pain. The examiner found no current low back disorder. During the examination, the Veteran reported episodes of low back pain while in-service. The examiner stated they were unable to locate documentation of these episodes. A review of the record showed a December 1997 STR that indicated back pain persisting for two days. Remand is thus required. Increased evaluation Remand is required in this case for clarification. An October 2018 VA examination was conducted. The examiner found the examination was conducted during a flare-up and noted that the Veteran reported reduced range of motion during a flare-up. Later, the examiner found that pain, weakness, fatigability, incoordination, did not significantly limit functional ability during a flare-up, but provided no explanation. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Remand for a supporting explanation is thus required. TDIU Lastly, remand is required because entitlement to TDIU is inextricably interwined with the pending increased evaluation claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his attorney. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. 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. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his bilateral knee disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. First, the examiner must comment on whether there is a bilateral knee disorder or whether any complaints of bilateral knee pain alone have resulted in functional impairment of earning capacity. The examiner must specifically address a November 2009 VA examination that showed mild patellofemoral knee strain and the Veteran’s lay statements of pain. Second, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any diagnosed bilateral knee disorder had onset in, or is otherwise related to, active military service. The examiner must specifically address the Veteran’s assertions of in-service knee pain and a November 2009 VA examination that showed mild patellofemoral knee strain. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his low back disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. First, the examiner must comment on whether there is a low back disorder or whether any complaints of low back pain alone have resulted in functional impairment of earning capacity. Second, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that a low back disorder had onset in, or is otherwise related to, active military service. The examiner must specifically address: 1) the Veteran’s assertions of in-service back pain and 2) a December 1997 complaint of back pain contained in the Veteran’s STRs. 5. After any additional records are associated with the claims file, obtain an addendum opinion regarding the severity of the service-connected left shoulder disability. The entire claims file must be made available to and be reviewed by the examiner. An explanation for all opinions expressed must be provided. The examiner must provide an explanation for the finding in the October 2018 VA examination that flare-ups od not cause significant limits on functional ability. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Bruton, Associate Counsel