Citation Nr: 18152313 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 16-28 884 DATE: November 21, 2018 ORDER The request to reopen the finally disallowed claim of entitlement to service connection for a right shoulder condition is granted. Entitlement to an effective date prior to November 17, 2011, for the grant of service connection for hepatitis C, is denied. REMANDED The issue of entitlement to service connection for a generalized bone/joint disorder, to include rheumatoid arthritis affecting the low back, elbows, hands, hips, shoulders, and knees, to include as secondary to service-connected hepatitis C. The issue of entitlement to service connection for a low back condition, to include degenerative arthritis and intervertebral disc syndrome, to include as secondary to service-connected hepatitis C and/or nonservice-connected ulcerative colitis. The issue of entitlement to service connection for a bilateral elbow condition, to include olecranon bursitis and lateral epicondylitis, to include as secondary to service-connected hepatitis C and/or nonservice-connected ulcerative colitis. The issue of entitlement to service connection for a bilateral hand condition, to include degenerative arthritis and bilateral hand sprains, to include as secondary to service-connected hepatitis C and/or nonservice-connected ulcerative colitis. The issue of entitlement to service connection for a bilateral hip condition, to include osteoarthritis and trochanteric area bursitis, to include as secondary to service-connected hepatitis C and/or nonservice-connected ulcerative colitis. The issue of entitlement to service connection for a bilateral shoulder condition, to include bicipital tenosynovitis, tendonitis, and shoulder strain, to include as secondary to service-connected hepatitis C and/or nonservice-connected ulcerative colitis. The issue of entitlement to service connection for a bilateral knee condition, to include degenerative arthritis and meniscal tear, to include as secondary to service-connected hepatitis C and/or nonservice-connected ulcerative colitis. The issue of entitlement to service connection for ulcerative colitis, to include as secondary to service-connected hepatitis C. The issue of entitlement to service connection for anemia, to include as secondary to service-connected hepatitis C. The issue of entitlement to service connection for a condition manifested by ulcers of the oral soft tissues, to include as secondary to service-connected hepatitis C. The issue of entitlement to an initial rating in excess of 20 percent for hepatitis C. The issue of entitlement to a total disability rating based on individual unemployability (TDIU). FINDINGS OF FACT 1. In a February 1972 rating decision, the RO denied a claim of entitlement to service connection for a right shoulder condition. No timely appeal was received by VA, nor was any new and material evidence submitted within the applicable appeal period. 2. Additional evidence received since the RO’s February 1972 decision is new to the record and relates to an unestablished fact necessary to substantiate the merits of the claim of entitlement to service connection for a right shoulder condition and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a right shoulder condition. 3. In a February 1972 rating decision, the RO denied a claim of entitlement to service connection for hepatitis. No timely appeal was received by VA, nor was any new and material evidence submitted within the applicable appeal period. 4. The Veteran’s application to reopen a claim of entitlement to service connection for hepatitis C was included on a VA Form 21-526, “Veteran’s Claim for Compensation and/or Pension,” date-stamped as received by VA on November 17, 2011. 5. There is no evidence dated between the February 1972 rating decision and the November 17, 2011 claim that may be interpreted as a formal or informal claim of entitlement to service connection for hepatitis C. CONCLUSIONS OF LAW 1. The February 1972 rating decision is final as to the claim of entitlement to service connection for a right shoulder condition. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.156, 20.1103 (2017). 2. New and material evidence has been presented to reopen the claim of entitlement to service connection for a right shoulder condition. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The criteria for an effective date prior to November 17, 2011, for the award of service connection for hepatitis C, have not been met. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5103A, 5107, 5110, 5126, 7105 (2012); 38 C.F.R. §§ 3.155, 3.157(b) (in effect prior to March 24, 2015); 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.400 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1969 to June 1971. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Offices (RO) in Augusta, Maine and Boston, Massachusetts. In a September 2013 rating decision, the Augusta RO granted entitlement to service connection for hepatitis C and assigned a 20 percent rating, effective from November 17, 2011, and denied entitlement to service connection for anemia, ulcerative colitis, arthritis, bone problems, bursitis, cartilage loss, tendinitis, joint problems, and soft tissue problems, all as secondary to hepatitis C. The Veteran timely perfected an appeal as to the rating and effective date assigned for hepatitis C, as well as the service connection issues. See July 2014 Notice of Disagreement; May 2016 Statement of the Case; June 2016 VA Form 9. In a January 2015 rating decision, the Boston RO denied entitlement to a TDIU, and the Veteran timely perfected an appeal. See March 2015 Notice of Disagreement; May 2016 Statement of the Case; June 2016 VA Form 9. The issue of entitlement to service connection for a right shoulder condition was previously denied in a February 1972 rating decision. The Board acknowledges that the RO reopened and denied the Veteran’s claim on the merits. Despite the determination reached by the RO, the Board must make its own determination as to whether new and material evidence has been received to reopen the Veteran’s claim. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). The issues have been recharacterized accordingly. Regarding the Veteran’s claim of entitlement to service connection for various musculoskeletal conditions that he contends are related to his service-connected hepatitis C, the Board notes that the Veteran’s initial claim was for “joint problems, cartilage loss, tendonitis, bursitis, and arthritis.” See November 2017 VA Form 21-526. In a January 2012 VA Form 21-4138, “Statement in Support of Claim,” the Veteran also asserted that he had “bone problems” as a result of hepatitis C. In the September 2013 rating decision, the RO adjudicated these issues as entitlement to service connection for joint problems, cartilage loss, tendonitis, bursitis, arthritis, and bone problems. Pursuant to relevant case law, a veteran may identify the scope of a claim by reference “to a body part or system that is disabled or by describing symptoms of the disability.” The factors for the adjudicator to consider, in determining the scope of a claim, are a veteran’s descriptions of the claim and symptoms as well as the information submitted, or obtained by VA, in support of the claim. See Clemons v. Shinseki, 23 Vet. App. 1 (2009); Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009). In the present case, the evidence developed during the processing of this claim reflects diagnoses of several low back, elbow, hand, hip, knee, and shoulder degenerative/osteo-arthritic conditions, as well as the Veteran’s contention that he has a generalized bone/joint disorder, such as rheumatoid arthritis, which is secondary to his service-connected hepatitis C. Given the foregoing, the Board has recharacterized the issues to reflect a claim for service connection for the individually affected joints and expanded the scope of the claim to include a generalized bone/joint disorder as styled above. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) (recognizing that separately diagnosed psychiatric conditions could be service connected, but could not be separately rated unless they resulted in different manifestations); see also Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008) (claims based on distinctly diagnosed diseases must be considered as separate and distinct claims). This will provide the most favorable review of the Veteran’s claim in keeping with the Court’s holdings in Clemons and Brokowski. I. New and Material Evidence The Veteran’s claim of entitlement to service connection for a right shoulder condition was previously denied, and the Veteran seeks to reopen the claim. In general, RO rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108; Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). 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 (a). VA must review all of the evidence submitted since the last final rating decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). The credibility of the evidence is presumed for the purpose of reopening, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216 (1995); Justus v. Principi, 3 Vet. App. 510 (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). Furthermore, 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, either by triggering the Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. With respect to the issue of materiality, the newly presented evidence need not be probative of all the elements required to award the service connection claim. In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a Veteran’s injury or disability, even where it would not be enough to convince the Board to grant a claim. The Veteran initially filed a claim of entitlement to service connection for a right shoulder condition in September 1971. In a February 1972 rating decision, the RO denied the claim on the basis that the evidence failed to show a diagnosis of a right shoulder condition. The Veteran was notified of the decision and his appellate rights by a letter dated in March 1972. The Veteran did not appeal that decision, nor did he submit any new and material evidence within a year of that rating decision. The February 1972 rating decision therefore became final. See 38 U.S.C. § 7105 (c); 38 C.F.R. § 20.1103. Relevant evidence of record at the time of the RO’s February 1972 rating decision included the Veteran’s service treatment records and a VA examination report. Based on this evidence, the RO concluded that the Veteran did not have a currently diagnosed right shoulder condition and denied the Veteran’s claim for service connection. In November 2011, the Veteran requested that his claim of entitlement to service connection for a right shoulder condition be reopened. Relevant additional evidence received since the RO’s February 1972 rating decision includes VA and private treatment records showing a current right shoulder diagnosis. This evidence was not previously on file at the time of the RO’s February 1972 decision; thus, it is new. Furthermore, this evidence is material because it relates to a current diagnosis of a right shoulder condition, which was one of the reasons the Veteran’s claim was previously denied. See Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). Accordingly, the claim of entitlement to service connection for a right shoulder condition is reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). The underlying claim is addressed further in the Remand section below. II. Earlier Effective Date The Veteran seeks an effective date earlier than November 17, 2011, for the grant of service connection for hepatitis C. See July 2014 Notice of Disagreement. The effective date for the grant of service connection based upon an original claim, a claim reopened after final disallowance, or a claim for increase is either the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service; otherwise it will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110 (b)(1); 38 C.F.R. § 3.400 (b). The effective date for a grant of benefits on the basis of the receipt of new and material evidence received after final disallowance, or in the case of reopened claims, is the date of the receipt of the new claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (q)(1)(ii), (r). The Court has held that when a claim is reopened, the effective date cannot be earlier than the date of the claim to reopen. Juarez v. Peake, 21 Vet. App. 537, 539-40 (2008) (citing Bingham v. Nicholson, 421 F.3d 1346 (Fed. Cir. 2005); Leonard v. Nicholson, 405 F.3d 1333, 1337 (Fed. Cir. 2005); Flash v. Brown, 8 Vet. App. 332, 340 (1995)). Here, the Veteran submitted a claim for entitlement to service connection for hepatitis in September 1971. The RO denied the claim in a February 1972 rating decision. The Veteran did not initiate an appeal of this decision, nor did VA actually or constructively receive any new and material evidence within a year following the decision; therefore, the decision became final. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104 (a), 3.156(b), 20.302, 20.1103. The remaining way the Veteran could attempt to overcome the finality of the February 1972 decision is to request a revision of that decision based on clear and unmistakable error (CUE). See 38 U.S.C. § 5109A (a) (“[A] decision by the Secretary... is subject to revision on the grounds of clear and unmistakable error. If evidence establishes the error, the prior decision shall be reversed or revised.”); see also Rudd v. Nicholson, 20 Vet. App. 296 (2006) (finding that only a request for revision based on CUE could result in the assignment of an effective date earlier than the date of a final decision). However, CUE in the prior RO decision has not been alleged and is not before the Board. Accordingly, the February 1972 rating decision, which denied entitlement to service connection for hepatitis, is final. On November 17, 2011, the Veteran filed a claim to reopen his previously denied claim of entitlement to service connection for hepatitis. A September 2013 rating decision granted entitlement to service connection for hepatitis and assigned an effective date of November 17, 2011. As noted above, the Court has held that when a claim is reopened, the effective date cannot be earlier than the date of the claim to reopen. Juarez v. Peake, 21 Vet. App. 537, 539-40 (2008) (citing Bingham v. Nicholson, 421 F.3d 1346 (Fed. Cir. 2005); Leonard v. Nicholson, 405 F.3d 1333, 1337 (Fed. Cir. 2005); Flash v. Brown, 8 Vet. App. 332, 340 (1995)). Therefore, the earliest effective date for the grant of entitlement to service connection for hepatitis C can be no earlier than the Veteran’s claim to reopen, which is November 17, 2011. The Board has reviewed the evidence to determine whether any communication submitted by the Veteran after the February 1972 rating decision indicates an attempt to reopen his claim for service connection for hepatitis. However, the Board finds that no other correspondence or communication received by VA before November 17, 2011, can be reasonably construed as an intent to file a formal or informal claim to reopen the previously denied claim of entitlement to service connection for hepatitis. The Veteran has not identified any document in the claims file that he contends is a pre-November 2011 claim to reopen. The Board acknowledges the private treatment records showing treatment for and a diagnosis of hepatitis C as early as 1999. These records do not support the assignment of an earlier effective date because they were not received by VA until January 2012, after the Veteran filed his claim to reopen on November 17, 2011. Thus, even assuming, arguendo, that these records could be construed as an informal claim for benefits, because they are private treatment records, the earliest date of such informal claim would be January 24, 2012, the date of receipt of such evidence by VA. See 38 C.F.R. § 3.157 (in effect prior to March 24, 2015). The Board observes that the laws and regulations governing effective dates are clear. The effective date for a grant of benefits on the basis of the receipt of new and material evidence received after final disallowance, or in the case of reopened claims, is the date of the receipt of the new claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (q)(1)(ii), (r). In this case, VA received the Veteran’s application to reopen a previously denied claim of entitlement to service connection for hepatitis on November 17, 2011. The record contains no statement or communication from the Veteran prior to November 17, 2011 that could reasonably constitute a pending claim for service connection for hepatitis. Nor does the Veteran contend that he filed a claim earlier than November 17, 2011. Based on the facts in this case, there is no legal basis for an effective date prior to November 17, 2011, for the award of service connection for hepatitis C. Because the RO did not receive a formal or informal application for to reopen a claim of service connection for hepatitis prior to November 17, 2011, VA is precluded, as a matter of law, from granting an effective date prior to November 17, 2011, for service connection for hepatitis C. As such, this appeal must be denied because the RO has already assigned the earliest possible effective date provided by law. Accordingly, the Board must deny the claim for entitlement to an earlier effective date for service connection for hepatitis C. As the preponderance of the evidence is against this claim, under these circumstances the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). REASONS FOR REMAND After a careful review of the Veteran’s claims file, the Board finds that further development is required prior to adjudicating the remaining issues on appeal. Service Connection The Veteran seeks service connection for ulcerative colitis, anemia, a condition manifested by ulcers of the oral soft tissues, a generalized joint/bone condition, such as rheumatoid arthritis, and low back, elbow, hand, hip, knee, and shoulder conditions, all as secondary to his service-connected hepatitis C. In May 2012, the Veteran submitted an abstract of an academic study regarding hepatitis C-related arthropathy. In an August 2013 opinion, a VA examiner, who did not examine the Veteran, noted that the Veteran “has multiple symptoms but has not been medically evaluated for them.” The examiner indicated that the Veteran had been diagnosed with Chron’s disease, “which is not related to Hep C.” The examiner also noted that the Veteran “has joint pain but has not been evaluated to rule out RA which can be caused by Hep C.” After listing the extrahepatic complications of hepatitis C, the examiner stated that “[w]ithout evaluating the [V]eteran for all [of] his complaints[,] [I] cannot resolve this issue without resorting to mere speculation.” The examiner also indicated that the Veteran “is only providing symptoms and not diagnoses.” In a March 2015 letter, the Veteran’s treating physician, Dr. M.E., noted that the Veteran suffered from chronic dry mouth, chronic arthritis of the knees, shoulders, elbows, back, hands, and hips, and ulcerative colitis. Dr. M.E. indicated that “[t]hese medical issues could be considered results of the prior infection with Hepatitis C from 1970.” In another March 2015 letter, Dr. M.E., noted that the treatment to control the symptoms of the Veteran’s ulcerative colitis “severely compromises his immune system.” Dr. M.E. reiterated that the Veteran’s “medical issues could be considered the result of a prior infection with Hepatitis C which was contracted sometime between 1969 and 1971 and undetected and untreated until 1998.” The Board notes that these opinions, standing alone, are inadequate. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (“A mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor’s opinion.”). In an April 2015 letter, another of the Veteran’s treating physicians, Dr. U.P.R., noted that a side effect of the Veteran’s ulcerative colitis treatment was arthralgia. In April 2016, the Veteran underwent several VA examinations, including for hepatitis, back conditions, elbow and forearm conditions, hand and finger conditions, hip and thigh conditions, knee and lower leg conditions, and shoulder and arm conditions. Regarding a low back condition, the examiner diagnosed the Veteran with osteoarthritis of the lumbar spine and degenerative disc disease. The examiner opined that it was less likely as not related to service-connected hepatitis C because “the [V]eteran has a known cause of his back pain with documented arthritis” and because “[h]epatitis C is not a known specific cause of low back pain.” The examiner concluded that “[g]iven the [V]eteran[’]s known arthritis, it would be speculation to link the [V]eteran’s back pain to hepatitis C.” Regarding a bilateral elbow condition, the examiner opined that it was less likely as not related to service-connected hepatitis C because “the [V]eteran is diagnosed with bilateral elbow bursitis” and because “[h]epatitis C is not a known specific cause of bilateral elbow bursitis.” The examiner concluded that “it would be speculation to link the [V]eteran’s bilateral elbow pain to hepatitis C.” Regarding a bilateral hand condition, the examiner diagnosed the Veteran with degenerative arthritis and bilateral hand sprain. The examiner opined that it was less likely as not related to service-connected hepatitis C because “the [V]eteran is diagnosed with bilateral hand sprain” and because “[h]epatitis C is not a known specific cause of bilateral hand pain/sprain.” The examiner concluded that “it would be speculation to link the [V]eteran’s bilateral hand pain to hepatitis C.” Regarding a bilateral hip condition, the examiner diagnosed the Veteran with osteoarthritis of the bilateral hips. The examiner opined that it was less likely as not related to service-connected hepatitis C because “the [V]eteran has a known cause of his hip pain with documented arthritis” and because “[h]epatitis C is not a known specific cause of bilateral hip pain.” The examiner concluded that “[g]iven the [V]eteran[’]s known arthritis, it would be speculation to link the [V]eteran’s hip pain to hepatitis C.” Regarding a bilateral knee condition, the examiner diagnosed the Veteran with osteoarthritis of the bilateral knees and right knee meniscus tear. The examiner opined that it was less likely as not related to service-connected hepatitis C because “the [V]eteran has a known cause of his knee pain with documented arthritis” and because “[h]epatitis C is not a known specific cause of bilateral knee pain.” The examiner concluded that “[g]iven the [V]eteran[’]s known arthritis, it would be speculation to link the [V]eteran’s hip [sic] pain to hepatitis C.” Regarding a bilateral shoulder condition, the examiner diagnosed the Veteran with bilateral shoulder strain. The examiner opined that it was less likely as not related to service-connected hepatitis C because “the [V]eteran is diagnosed with bilateral shoulder strain” and because “[h]epatitis C is not a known specific cause of bilateral shoulder strain.” The examiner concluded that “it would be speculation to link the [V]eteran’s shoulder pain to hepatitis C.” In July 2017, the Veteran, through his representative, submitted to academic research studies discussing the correlation between hepatitis C and arthritis, including possible rheumatic manifestations in individuals with hepatitis C and how arthritis can be caused by viral infections, such as hepatitis. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the August 2013 VA examiner noted that he could not provide an opinion regarding the relationship between the Veteran’s claimed conditions and hepatitis C without first examining the Veteran. The April 2016 VA examiner’s opinions are conclusory and do not take into account all of the Veteran’s diagnoses and contentions, and the examiner did not offer an opinion regarding the aggravation aspect of secondary service connection. The Court has made it clear than an opinion will be considered inadequate unless it addresses both the “caused by” and “aggravation” avenues for secondary service-connection. El-Amin v. Shinseki, 26 Vet. App. 136 (2013). Further, the April 2016 VA examiner did not discuss the May 2012 treatise evidence or the March 2015 and April 2015 private opinions. Additionally, since the April 2016 examination, additional treatise evidence has been associated with the claims file. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board’s duty to return an inadequate examination report “if further evidence or clarification of the evidence...is essential for a proper appellate decision”). Moreover, no opinion has been obtained regarding the relationship between the Veteran’s diagnosed ulcerative colitis, anemia, and oral ulcers and his service-connected hepatitis C. Nor has the Veteran been evaluated for a generalized joint/bone condition, such as rheumatoid arthritis, that may be related to service-connected hepatitis C. In light of the foregoing, the Veteran should be afforded new VA examinations which address the nature and etiology of all of the Veteran’s claimed conditions and their relationship, if any, to his service-connected hepatitis C. Increased Rating for Hepatitis and TDIU The Board notes that arthralgia is one of the symptoms listed in the rating criteria for hepatitis C. See 38 C.F.R. § 4.114, Diagnostic Code 7354. Although sequelae of hepatitis C may be evaluated separately, the same signs and symptoms may not be used as the basis for evaluation under Diagnostic Code 7354 and a diagnostic code evaluating sequelae. See Note (1), Diagnostic Code 7354; see also Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) (“Section 4.14 clearly contemplates that several separately diagnosed disorders may have a single manifestation, and it clearly prohibits the VA from rating that manifestation for each disorder”). As such, the decision relating to entitlement to service connection for the Veteran’s various arthritis claims could affect which of the Veteran’s symptoms are contemplated in determining his ultimate disability evaluation for hepatitis C. See Amberman, 570 F.3d at 1381. Therefore, any review of the decision on the increased rating claim for hepatitis C would be rendered meaningless and a waste of appellate resources. Therefore, the Board finds that the claim of entitlement to an increased rating for hepatitis C must also be remanded, as it is inextricably intertwined with the service connection claims discussed above. See Henderson v. West, 12 Vet. App. 11, 20 (1998), Harris v. Derwinski, 1 Vet. App. 180 (1991); Parker v. Brown, 7 Vet. App. 116, 118 (1994). Similarly, the TDIU issue is inextricably intertwined with the issues remanded herein. Thus, adjudication of the TDIU issue is also deferred. See Harris v. Derwinski, 1 Vet. App. at 183 (1990) (two issues are inextricably intertwined when they are so closely tied together that a final decision on one could have a negative impact on the other). Lastly, as the record reflects that the Veteran receives ongoing private treatment for the issues on appeal, any updated treatment records should be obtained on remand. The matters are REMANDED for the following action: 1. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to enable it to obtain any additional evidence pertinent to the claim on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, any pertinent, outstanding private records. 2. After all available records have been associated with the claims file, schedule the Veteran for an appropriate VA examination(s) to determine the current nature and likely etiology of his diagnosed ulcerative colitis, anemia, and oral tissue ulcers. The entire claims file, to include a complete copy of this remand must be made available to and reviewed by the examiner. All indicated studies, tests, and evaluations deemed necessary should be performed. After examining the Veteran and reviewing the claims file, the examiner(s) should address each of the following questions: (b.) Is it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s ulcerative colitis is proximately due to or caused by the Veteran’s service-connected hepatitis C? If not, is it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s ulcerative colitis was aggravated (permanently worsened in severity beyond a natural progression) by the Veteran’s service-connected hepatitis C? If the examiner determines that the Veteran’s ulcerative colitis was aggravated by the service-connected hepatitis C, the examiner should report the baseline level of severity of the ulcerative colitis prior to the onset of aggravation. If some of the increase in severity of the ulcerative colitis is due to the natural progress of the disease, the examiner should indicate the degree of such increase in severity due to the natural progression of the disease. In providing these opinions, the examiner must review and discuss the March 2015 statements of Dr. M.E. and the April 2015 statement of Dr. U.P.R. If necessary, and to the extent possible, the examiner should reconcile his opinion with this evidence. (c.) Is it as it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s anemia is proximately due to or caused by the Veteran’s service-connected hepatitis C? If not, is it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s anemia was aggravated (permanently worsened in severity beyond a natural progression) by the Veteran’s service-connected hepatitis C? If the examiner determines that the Veteran’s anemia was aggravated by the service-connected hepatitis C, the examiner should report the baseline level of severity of the anemia prior to the onset of aggravation. If some of the increase in severity of the anemia is due to the natural progress of the disease, the examiner should indicate the degree of such increase in severity due to the natural progression of the disease. In providing these opinions, the examiner must review and discuss the March 2015 statements of Dr. M.E. and the April 2015 statement of Dr. U.P.R. If necessary, and to the extent possible, the examiner should reconcile his opinion with this evidence. (d.) Is it as it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s oral ulcers are proximately due to or caused by the Veteran’s service-connected hepatitis C? If not, is it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s oral ulcers were aggravated (permanently worsened in severity beyond a natural progression) by the Veteran’s service-connected hepatitis C? If the examiner determines that the Veteran’s oral ulcers was aggravated by the service-connected hepatitis C, the examiner should report the baseline level of severity of the oral ulcers prior to the onset of aggravation. If some of the increase in severity of the oral ulcers is due to the natural progress of the disease, the examiner should indicate the degree of such increase in severity due to the natural progression of the disease. The examiner’s report must reflect consideration of the Veteran’s entire documented medical history and assertions and all lay evidence. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 3. After all available records have been associated with the claims file, schedule the Veteran for an appropriate VA examination(s) to determine the current nature and likely etiology of his low back, bilateral elbow, bilateral hand, bilateral hip, bilateral knee, and bilateral shoulder conditions. The entire claims file, to include a complete copy of this remand must be made available to and reviewed by the examiner. All indicated studies, tests, and evaluations deemed necessary should be performed. After examining the Veteran and reviewing the claims file, the examiner(s) should address each of the following questions: (a.) Does the Veteran have a generalized bone/joint condition, such as rheumatoid arthritis, and, if so, which specific joints does the condition affect? (b.) If the Veteran does have a generalized bone/joint condition, such as rheumatoid arthritis, is it as it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s condition is proximately due to or caused by the Veteran’s service-connected hepatitis C? If not, is it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s condition was aggravated (permanently worsened in severity beyond a natural progression) by the Veteran’s service-connected hepatitis C? If the examiner determines that the Veteran’s condition was aggravated by the service-connected hepatitis C, the examiner should report the baseline level of severity of the condition prior to the onset of aggravation. If some of the increase in severity of the condition is due to the natural progress of the disease, the examiner should indicate the degree of such increase in severity due to the natural progression of the disease. (c.) Notwithstanding the answer to questions (a) and (b), is it at least as likely as not (i.e., a 50 percent or greater probability) that any of the Veteran’s currently diagnosed low back, bilateral elbow, bilateral hand, bilateral hip, bilateral knee, and bilateral shoulder conditions was proximately due to or caused by the Veteran’s service-connected hepatitis C? If not, is it at least as likely as not (i.e., 50 percent probability or greater) that any of the Veteran’s currently diagnosed low back, bilateral elbow, bilateral hand, bilateral hip, bilateral knee, and bilateral shoulder conditions was aggravated (permanently worsened in severity beyond a natural progression) by the Veteran’s service-connected hepatitis C? If the examiner determines that the Veteran’s condition was aggravated by the service-connected hepatitis C, the examiner should report the baseline level of severity of the condition prior to the onset of aggravation. If some of the increase in severity of the condition is due to the natural progress of the disease, the examiner should indicate the degree of such increase in severity due to the natural progression of the disease. In providing these opinions, the examiner must review and discuss the March 2015 statements of Dr. M.E. and the April 2015 statement of Dr. U.P.R; the treatise evidence submitted by the Veteran in May 2012 regarding hepatitis C-related arthropathy; and the treatise evidence submitted by the Veteran’s representative in July 2017 discussing the correlation between hepatitis C and arthritis, including possible rheumatic manifestations in individuals with hepatitis C and how arthritis can be caused by viral infections, such as hepatitis. If necessary, and to the extent possible, the examiner should reconcile his opinion with this evidence. (Continued on the next page)   The examiner’s report must reflect consideration of the Veteran’s entire documented medical history and assertions and all lay evidence. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 4. Following the completion of the foregoing, and any other development deemed necessary, the AOJ should readjudicate the Veteran’s claim. If the claim is denied, supply the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Kipper, Associate Counsel