Citation Nr: 18152704 Decision Date: 11/27/18 Archive Date: 11/23/18 DOCKET NO. 18-15 974 DATE: November 27, 2018 ORDER Entitlement to an effective date prior to February 16, 2016, for the assignment of service connection for radiculopathy of the bilateral lower extremities, is denied. Entitlement to an effective date prior to February 16, 2016, for the assignment of service connection for a right knee disorder, is denied. Entitlement to a rating for a lumbar spine disorder in excess of 10 percent prior to February 16, 2016, and in excess of 20 percent thereafter, is denied. Entitlement to a rating in excess of 20 percent for radiculopathy of the bilateral lower extremities is denied. Entitlement to a compensable rating for bilateral hearing loss is denied. Entitlement to a rating for a right knee disorder in excess of 10 percent is denied. Entitlement to a rating for a left knee disorder in excess of 10 percent is denied. New and material evidence having not been received, the application to reopen a previously denied claim for entitlement to service connection for obstructive sleep apnea is denied, and the claim is not reopened. Entitlement to service connection for a bilateral foot disorder is denied. REMANDED Entitlement to service connection for a bilateral hand disorder is remanded. Entitlement to service connection for a toes disorder is remanded. Entitlement to service connection for chest pain is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a gastrointestinal disorder is remanded. Entitlement to service connection for an anal condition, to include diverticulosis and hemorrhoids, is remanded. Entitlement to service connection for keratoderma is remanded. Entitlement to service connection for type 2 diabetes mellitus is remanded. Entitlement to service connection for a head condition is remanded. FINDINGS OF FACT 1. The evidence of record does not demonstrate that the Veteran suffered from radiculopathy of the bilateral lower extremities prior to February 16, 2016. 2. The Veteran was previously denied service connection for a right knee disorder in March 2010, May 2011, October 2011, and December 2014 rating decisions. The December 2014 rating decision became final and the Veteran did not refile for service connection for a right knee disorder until February 16, 2016. 3. Prior to February 16, 2016, the Veteran’s back disorder was characterized by painful motion; forward flexion of not greater than 60 degrees, combined range of motion of the thoracolumbar spine not greater than 120 degrees, and muscle spasms and guarding were not shown. 4. From February 16, 2016, onwards, the Veteran’s back disorder has been characterized by forward flexion of between greater than 30 degrees and not greater than 60 degrees as well as muscle spasm severe enough to result in an abnormal gait or contour; ankylosis and forward flexion of 30 degrees of less has not been shown. 5. During the appeal period, the Veteran’s radiculopathy of the bilateral lower extremities has been characterized by moderate symptoms. 6. The Veteran’s hearing loss has been manifested by no worse than Level I hearing impairment bilaterally. 7. During the appeal period, the Veteran’s right knee has been characterized by flexion of 100 degrees and extension of 0 degrees; limitation of flexion to 30 degrees and limitation of extension to 15 degrees were not shown. 8. During the appeal period, the Veteran’s left knee has been characterized by flexion of 90 degrees and extension of 0 degrees; limitation of flexion to 30 degrees and limitation of extension to 15 degrees were not shown. 9. In December 2014, service connection for obstructive sleep apnea was denied; a notice of disagreement and/or new and material evidence was not submitted within one year of notice of that decision. 10. The evidence added to the record since the December 2014 decision does not relate to an unestablished fact necessary to substantiate the claim of entitlement to service connection for obstructive sleep apnea. 11. The preponderance of the evidence is against finding that he Veteran’s bilateral foot disorders began during active service, or are otherwise related to an in-service injury, event, or disease. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to February 16, 2016, for the assignment of service connection for radiculopathy of the bilateral lower extremities, have not been met. 38 U.S.C. §§ 5110, 7104; 38 C.F.R. § 3.400. 2. The criteria for an effective date prior to February 16, 2016, for the assignment of service connection for a right knee disorder, have not been met. 38 U.S.C. §§ 5110, 7104; 38 C.F.R. § 3.400. 3. The criteria for a rating for a lumbar spine disorder in excess of 10 percent prior to February 16, 2016, and in excess of 20 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5243. 4. The criteria for entitlement to a rating in excess of 20 percent for radiculopathy of the bilateral lower extremities have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 8520. 5. The criteria for entitlement to a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.85, 4.86a, DC 6100. 6. The criteria for entitlement to a rating for a right knee disorder in excess of 10 percent have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 5003-5260. 7. The criteria for entitlement to a rating for a left knee disorder in excess of 10 percent have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 5003-5261. 8. The December 2014 decision that denied the Veteran’s claim for entitlement to service connection for obstructive sleep apnea is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 9. As the evidence received subsequent to the December 2014 decision is not new and material, the requirements to reopen the claim for entitlement to service connection for obstructive sleep apnea are not met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.102, 3.156. 10. The criteria for entitlement to service connection for a bilateral foot disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1970 to October 1973. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2016 rating decision by the Department of Veterans Affairs (VA). In January 2012, the Veteran filed for service connection for arthritis, which VA has interpreted to apply to arthritis of the back and left knee. These two claims, among others, were addressed in a July 2013 rating decision. However, in the letter to the Veteran accompanying the decision, VA stated that the July 2013 rating decision was a provisional decision. He could submit additional evidence within one year and the decision may be reconsidered. VA further informed the Veteran that if he wanted a final decision with appeal rights before the one-year provisional period ends, he must send VA a statement. VA did not finalize its decision until May 2016, approximately three years later. As the Veteran’s July 2013 rating decision never became final until May 2016, by which time the Veteran had again filed increased rating claims for his back and left knee, the period on appeal for the increased rating for those two claims dates back to January 2012. Earlier Effective Date The effective date for a grant of service connection for reopened claims is the date of receipt of claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a), (b); 38 C.F.R. § 3.400(r). A claim is a formal or informal communication, in writing, requesting a determination of entitlement or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1(p). The provisions of 38 U.S.C. § 5101(a) mandate that a claim must be filed in order for any type of benefit to be paid. Jones v. West, 136 F.3d 1296, 1299 (Fed. Cir. 1998). Further, the mere presence of medical evidence in the record does not establish intent on the part of the Veteran to seek service connection for the benefit. The mere existence of medical records generally cannot be construed as an informal claim; rather, there must be some intent by the claimant to apply for a benefit. Brannon v. West, 12 Vet. App. 32, 34-35 (1989). 1. Entitlement to an effective date prior to February 16, 2016, for the assignment of service connection for radiculopathy of the bilateral lower extremities The Veteran is seeking an earlier effective date for the initial assignment of service connection for radiculopathy of the bilateral lower extremities. However, the Board concludes that an effective date prior to February 16, 2016, is not warranted. The Board recognizes that inasmuch as radiculopathy is a neurological manifestation of a spine disability, it is included with the increased rating claim for a spine disability. See 38 C.F.R. § 4.71a, Note 1. The Veteran sought an increased rating for his back condition in a January 6, 2012, statement. There is no indication of an intent to file for an increased rating prior to this date. The effective date of service connection is tied to the later date of the date of receipt of the claim or when entitlement arose. In this case, after a careful review of the medical evidence, the Board concludes that no evidence has been presented that the Veteran suffered from radiculopathy of the bilateral lower extremities prior to the date of the June 14, 2016, VA examination. In a December 2012 VA examination, the Veteran reported no radicular pain or any other signs or symptoms due to radiculopathy. The examiner concluded that the Veteran did not demonstrate any neurologic abnormalities or findings related to his back condition. Moreover, medical providers evaluated the Veteran and found no weakness or numbness of the extremities in February 2014, January 2015, and January 2016. The Board acknowledges that the examiner who conducted the June 2016 peripheral nerves examination noted a radiculopathy diagnosis date of 2010. However, the examiner did not explain how they came up with that date and there is no evidence in the claims file to support that finding. Therefore, the Board assigns that finding no probative value. Consequently, as the evidence demonstrates that the Veteran’s entitlement arose as to bilateral radiculopathy of the lower extremities on June 14, 2016, which is later than the January 2012, date of receipt of the claim, the Board finds that an effective date prior to February 16, 2016, is unwarranted. 2. Entitlement to an effective date prior to February 16, 2016, for the assignment of service connection for a right knee disorder The Veteran is seeking an earlier effective date for the assignment of service connection for his right knee disorder. However, the Board concludes that an effective date prior to February 16, 2016, is unwarranted. The Veteran’s claim for a right knee disorder was previously denied in March 2010, May 2011, October 2011, and December 2014 rating decisions. As to the December 2014 rating decision, he did not file a Notice of Disagreement or submit new and material evidence within one year of the decision. Therefore, the rating decision represents the last final denial of the claim. The effective date of service connection is tied to the later date of the date of receipt of the claim or when entitlement arose. The June 2016 VA examiner noted that the Veteran was diagnosed with degenerative arthritis of the right knee in July 2014; medical evidence demonstrates that he has suffered from right knee pain even prior to this date. However, the Veteran did not refile the claim for service connection for a right knee disorder until February 16, 2016. The Board has searched for submissions to VA that could constitute an informal claim that would warrant an earlier effective date. However, there is no indication of an intent to file for an increased rating prior to this date. Consequently, as the evidence demonstrates that the receipt of the request to reopen the claim for service connection for a right knee disorder was received on February 16, 2016, which is later than the July 2014 date that entitlement arose, the Board finds that an effective date prior to February 16, 2016, is unwarranted. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. While the Board typically considers only those factors contained wholly in the rating criteria, it is appropriate to consider factors outside the specific rating criteria when appropriate in order to best determine the level of occupational and social impairment. Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are as entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See 38 C.F.R. § 4.59. 3. Entitlement to a rating for a lumbar spine disorder in excess of 10 percent prior to February 16, 2016, and in excess of 20 percent thereafter 4. Entitlement to a rating in excess of 20 percent for radiculopathy of the bilateral lower extremities The Veteran has been assigned a rating for his lumbar spine disorder of 10 percent prior to February 16, 2016, and a rating of 20 percent thereafter. He has been assigned his rating under 38 C.F.R. § 4.71a, DC 5243, addressing intervertebral disc syndrome of the spine (IVDS). He filed a claim for an increased rating for his back disorder in January 2012. Diagnostic Code 5243, referring to IVDS, enables a veteran to be rated under the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating IVDS Based on Incapacitating Episodes. The rating formula that results in the higher evaluation should be the one utilized. Importantly, if a veteran is rated based on incapacitating episodes, he is unable to obtain a separate rating for radiculopathy. In that regard, the diagnostic code pertaining to IVDS contemplates the effects of related neurological manifestations. Evaluating a veteran under IVDS along with the assignment of separate ratings for radiculopathy would constitute impermissible pyramiding. See 38 C.F.R. § 4.14. As an initial matter, the Board determines that the Veteran’s disability should not be rated based on incapacitating episodes, as there is no evidence that he has been prescribed periods of bed rest by a physician. Specifically, the June 2016 VA examiner noted that the Veteran had no incapacitating episodes over the previous 12 months period and the March 2017 VA examiner questioned the IVDS diagnosis. Regardless, no incapacitating episodes have been shown. Instead, it is more proper to rate the Veteran’s back disorder under the General Rating Formula for Diseases and Injuries of the Spine. Under 38 C.F.R. § 4.71a, DC 5243, a 20 percent evaluation is warranted when the evidence shows: • Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; • Combined range of motion of the thoracolumbar spine not greater than 120 degrees; or • Muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. By comparison, a 40 percent rating is warranted when the evidence shows: • Forward flexion of the thoracolumbar spine to 30 degrees or less; or • Favorable ankylosis of the entire thoracolumbar spine. Ankylosis is the “immobility and consolidation of a joint due to disease, injury, surgical procedure.” See Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). Note (1) to the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes defines an “incapacitating episode” as a “period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.” See 38 C.F.R. § 4.71a. First, the Board concludes that a rating in excess of 10 percent is not warranted prior to February 16, 2016. During a December 2012 VA examination, the Veteran reported pain while bending, rising, lifting, and carrying. He took no specific medication, but did receive injections. His range of motion was insufficient to warrant a higher rating. These measurements took into account both painful and repetitive motion. Range of motion testing revealed a forward flexion of 90 degrees or greater, extension of 20 degrees, bilateral lateral flexion of 25 degrees, and bilateral lateral rotation of 30 degrees or greater. The combined range of motion is far in excess of 120 degrees. Additionally, the Veteran did not exhibit guarding or muscle spasm of the thoracolumbar spine, which could warrant a higher rating. Although flare-ups caused back pain with standing, walking, and sitting, there is no indication that it caused additional functional loss. Based off of the evidence in the claims file, the Board finds that the Veteran does not meet the criteria necessary for a rating in excess of 10 percent prior to February 16, 2016. Next, the Board finds that a rating for the Veteran’s back disorder in excess of 20 percent is not warranted from February 16, 2016, onwards. The Veteran underwent VA examinations in June 2016 and March 2017. These examinations did not reveal a forward flexion of 30 degrees or less or ankylosis. During the June 2016 VA examination, the Veteran reported worsening back pain that radiated below his knees. Range of motion testing revealed a forward flexion of 60 degrees even after accounting for pain, flare-ups, and repetitive motion. At the March 2017 VA examination, the Veteran complained of ongoing back pain and trouble getting himself going in the morning. Range of motion testing revealed a forward flexion of 75 degrees, which the examiner deemed normal after taking into account the Veteran’s obesity. Both examiners agreed that the Veteran did not demonstrate ankylosis. Consequently, the Board finds that the Veteran does not meet the criteria necessary for a rating in excess of 20 percent from February 16, 2016, onwards. Neurological Abnormalities When evaluating the extent of a Veteran’s spine disability, the Board is required to consider whether a separate evaluation is warranted for any associated neurological abnormality including, but not limited to, bowel or bladder impairment, neurological impairment in the extremities or other such disorders, which are to be evaluated under the appropriate diagnostic code. See 38 C.F.R. § 4.71(a), Note 1. In this instance, the Veteran receives a pair of ratings for his radiculopathy of the bilateral lower extremities. He receives a 20 percent rating for each lower extremity under 38 C.F.R. § 4.124a, DC 8520, which addresses paralysis of the sciatic nerve. Under 38 C.F.R. § 4.124a, DC 8520, a 20 percent rating is warranted for incomplete paralysis of a moderate nature. By comparison, a 40 percent rating is warranted for incomplete paralysis of a moderately severe nature. The descriptive words “moderate,” “moderately severe,” and “severe,” as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for “equitable and just decisions.” 38 C.F.R. § 4.6. The Board has determined that a rating in excess of 20 percent is not warranted for the Veteran’s radiculopathy of the bilateral lower extremities. Specifically, the Veteran’s condition cannot be characterized as being worse than a moderate nature. During a June 2016 VA examination, the Veteran reported shocking pain down his legs to his ankles. He reported mild constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness. No moderate symptoms were noted and the examiner concluded that the Veteran only demonstrated symptoms of a mild nature. The Board acknowledges that the March 2017 VA examiner concluded that the Veteran does not have radicular pain or radiculopathy, citing the lack of evidence to support such a diagnosis. The Veteran did not specifically report radicular pain at the examination. However, the Board finds that the Veteran was competent to report pain in his legs during his June 2016 examination. Additionally, in a September 2016 addendum opinion, the June 2016 examiner noted objective findings of radiculopathy including bilateral sensory deficits and hyporeflexia. Therefore, the Board accepts the Veteran’s radiculopathy diagnosis. There remains the fact that the Veteran did not report radicular pain at his March 2017 VA examination and his medical records are absent of such symptoms during the appeal period. When the Veteran was evaluated in June 2016, the examiner only noted mild radiculopathy. As a result, the Board finds that there has been insufficient evidence presented to support evaluating the Veteran’s radiculopathy of the bilateral lower extremities as being worse than of a moderate nature. 5. Entitlement to a compensable rating for bilateral hearing loss The Veteran is seeking a compensable rating for his bilateral hearing loss. He states that it sometimes doesn’t sound clear when his family is talking. He also needs to turn up the volume of the television and radio to high levels in order to hear them. Ratings for hearing loss, which range from noncompensable to 100 percent, are based on an organic impairment of hearing acuity as demonstrated by the results of speech discrimination tests together with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies of 1,000, 2,000, 3,000, and 4,000 Hertz (Hz). The degree of disability from service-connected hearing loss is rated based on 11 auditory acuity levels with Level I, representing essentially normal acuity, through Level XI, representing profound deafness. See 38 C.F.R. § 4.85. An alternative rating method may be used when the pure tone threshold at each of the four specified frequencies (1,000, 2,000, 3,000, and 4,000 Hertz) is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1,000 Hz and 70 decibels or more at 2,000 Hz. 38 C.F.R. § 4.86. VA will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa based on whichever results in the higher numeral. Id. In hearing loss rating cases, an examination for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. Examinations are conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). The Board determines that a compensable rating is not warranted for the Veteran’s bilateral hearing loss. On the authorized audiological evaluation in June 2016, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Avg. RIGHT 35 45 45 40 41 LEFT 35 45 50 40 43 Speech audiometry revealed speech recognition ability of 94 percent bilaterally. When utilizing Table VI, the Veteran exhibits Level I hearing impairment bilaterally. After applying these results to Table VII, a noncompensable percent rating is for application. Therefore, based on the evidence of record, a compensable rating for bilateral hearing loss is not warranted. 6. Entitlement to a rating for a right knee disorder in excess of 10 percent 7. Entitlement to a rating for a left knee disorder in excess of 10 percent The Veteran is seeking a rating in excess of 10 percent for his bilateral knee disorder. Importantly, different appeal periods apply for each knee. The Veteran’s right knee is only service-connected as of February 16, 2016. However, the Veteran originally sought a higher rating for his left knee disability on January 6, 2012. Regarding knee claims, a claimant who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257 or 5258/5259. See VAOPGCPREC 23-97. For example, when a knee disorder is already rated under DC 5257 (addressing lateral instability), a separate rating may be warranted if the Veteran’s knee also shows limitation of motion which at least meets the criteria for a zero-percent rating under DC 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more). Initially, the Board notes that with regards to both of his knees, there are several diagnostic codes not for application. For example, he has not been shown to have ankylosis (DC 5256), recurrent subluxation or lateral instability (DC 5257), impairment of the tibia and fibula (DC 5262), or genu recurvatum (DC 5263). Additionally, the Board notes that the Veteran does not have a semilunar cartilage disability (DCs 5258 and 5259). The Board acknowledges that the June 2016 VA examiner noted a left side meniscal tear. However, during the Veteran’s March 2017 VA examination, both he and his wife denied that the Veteran has ever been diagnosed with any meniscal tear. The examiner also found insufficient evidence to support a diagnosis of a meniscal tear. Therefore, the Board finds that a rating for a semilunar cartilage disability would be inappropriate. As a result, in order to warrant a 20 percent rating for the Veteran’s knee disability, the evidence must show: • Limitation of flexion to 30 degrees (20 percent under DC 5260); or • Limitation of extension to 15 degrees (20 percent under DC 5261) 38 C.F.R. § 4.71a. With regards to his right knee, he receives a 10 percent rating under 38 C.F.R. § 4.71a, DC 5003-5260, indicating that his right knee is rated as degenerative arthritis analogous to limited flexion of the knee. The Board finds that a higher rating is unwarranted. During a June 2016 VA examination, he reported worsening right knee pain and that he uses a brace at night. He suffered from a flare about twice or more a week, lasting between two and four days, but he has had flares that last for weeks. During that time, he is more sedentary, unable to stand for long periods of time, and difficulty getting up from a low position or a seat. Range of motion testing revealed flexion of 100 degrees and extension of 0 degrees, which is insufficient for a higher rating. Importantly, there was no change in the range of motion based on pain, repeat motion, and flare-ups. The results from the March 2017 VA examination were consistent with the previous examination. The same range of motion was exhibited, which did not reach the necessary thresholds of limitation of flexion to 30 degrees or limitation of extension to 15 degrees. Consequently, the Board concludes that a rating in excess of 10 percent is not warranted for the Veteran’s right knee disability. As for the Veteran’s left knee, he receives a 10 percent rating under DC 5003-5261, indicating that his right knee is rated as degenerative arthritis analogous to limited extension of the knee. The Board finds that a higher rating is unwarranted. During a December 2012 VA examination, the Veteran complained of worsening left knee pain, especially when squatting, climbing, using stairs, and walking. Range of motion testing revealed flexion of 90 degrees and extension of 0 degrees. These measurements accounted for painful and repetitive motion. The evidence demonstrates that he suffered from knee pain throughout the appeal period. For example, in June 2013, he went to the emergency room and reported that prescribed painkillers had no effect. He was given an orthopedic wrap at that time. At his June 2016 VA examination, after taking repetitive motion into account, he exhibited flexion of 90 degrees and extension of 0 degrees. He suffered from a flare about twice or more a week, lasting between two and four days, but he has had flares that last for weeks. During that time, he is more sedentary, unable to stand for long periods of time, and difficulty getting up from a low position or a seat. The Veteran’s knee seems to have become somewhat better as of his March 2017 VA examination. He continued to report knee pain and a worsening. However, he exhibited flexion of 140 degrees and extension of 0 degrees. The measurements remained unchanged after taking into account pain and repeat motion. The Veteran did report flare-ups that cause his condition to become worse with prolonged activity, but there was no accompanying functional loss. Throughout the appeal period, there is insufficient evidence to demonstrate that the range of motion of his knee approached the 20 percent rating criteria thresholds of limitation of flexion to 30 degrees or limitation of extension to 15 degrees. Consequently, the Board concludes that a rating in excess of 10 percent is not warranted for the Veteran’s left knee disability. In considering the appropriate disability ratings for the above disorders, the Board has also considered the Veteran’s statements that his disabilities are worse than the ratings he currently receives. In rendering a decision on appeal, 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. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When considering the appropriate ratings for the Veteran’s musculoskeletal disorders, the Board has considered the impact of functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). In this case, the VA examiners took into account the functional limitations such as the Veteran’s limited ability to move during a flare-up. The additional functional loss caused by the pain is taken into account for his range of motion measurements. See Mitchell v. Shinseki, 25 Vet. App. 32, 37-43 (2011) (pain must affect some aspect of the normal working movements of the body such as strength, speed, coordination or endurance). Put another way, while the Veteran has complained of pain and difficulty moving, these complaints are adequately contemplated in the ratings he currently receives. Competency of evidence differs from weight and credibility. While the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability according to the appropriate diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). On the other hand, such competent evidence concerning the nature and extent of the Veteran’s disabilities have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which the disability is evaluated. New and Material Evidence In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999); Manio v. Derwinski, 1 Vet. App. 140 (1991). Under the relevant regulation, “new” evidence is defined as 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. If it finds that the submitted evidence is new and material, VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the veteran in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999); but see 38 U.S.C. § 5103A (eliminates the concept of a well-grounded claim). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low, and consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied. Rather, consideration should include 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. See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). 8. Whether new and material evidence has been received to reopen the claim for entitlement to service connection for obstructive sleep apnea The Veteran is seeking service connection for the previously-denied claim of obstructive sleep apnea. Based on the additional evidence added to the record since the previous final denial of the Veteran’s claim, the Board finds that new and material evidence has not been added to the record. The Veteran’s service connection claim for obstructive sleep apnea was denied in a December 2014 rating decision. A review of that rating decision reveals that at the time, VA declined to grant service connection because there was insufficient evidence to demonstrate that the condition occurred in or was caused by military service. He did not appeal that decision within one year, nor did he submit any new and material evidence within a year of receiving it. See Buie v. Shinseki, 24 Vet. App. 242 (2011). This represents the last final denial of the claim. Since the last final denial, the Veteran has submitted additional medical treatment records that document continued treatment of his obstructive sleep apnea. Despite the addition of treatment records, there remains no new and material evidence. VA does not dispute that the Veteran has a current diagnosis of obstructive sleep apnea. Rather, there remains no indication that his sleep apnea first manifested or is connected with military service. As evidence of continued treatment fails to show one of the missing necessary elements for service connection, the Board concludes that new and material evidence has not been added to the record and the claim is not reopened. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). VA must give due consideration to all pertinent medical and lay evidence in a case where a veteran is seeking service connection. 38 U.S.C. § 1154(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the veteran. 38 U.S.C. § 5107(b). 9. Entitlement to service connection for a bilateral foot disorder The Veteran is seeking service connection for a bilateral foot disorder. As he is separately appealing service connection for a bilateral toes disorder and keratoderma, the Board will not consider any toes-related or keratoderma conditions in its analysis. Initially, the Board acknowledges that the Veteran was not provided with a VA examination for his service-connection claim. However, the Board finds that a VA examination is not required here because competent evidence has not been presented indicating that the existence of a disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s active service. Additionally, there is no evidence to show that the claimed disabilities occurred in service or are associated with service. See McClendon v. Nicholson, 20 Vet App. 79 (2006). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has multiple diagnoses pertaining to his feet, the preponderance of the evidence is against finding that they began during active service, or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service treatment records do not reflect complaints of, treatment for, or a diagnosis related to a foot condition. The only pertinent notation in his service treatment records was in March 1971, when he complained of foot pain when he fell. However, the imaging report showed a left foot within normal limits and there were no notations after that demonstrating continuing symptoms. Significantly, his separation examination was absent of any complaints of or observed symptoms related to a foot condition. In fact, the post-service evidence does not reflect symptoms related to a foot disorder for many decades after the Veteran left active duty service in October 1973. The first indication of foot pain of an unknown etiology was in December 2008. In May 2012, he was diagnosed with metatarsalgia and foot pain. In March 2016, he was diagnosed with pes planus. As none of these disorders started during service or continued since the time of service, continuity is not established based on the clinical evidence. The Veteran himself has not specifically asserted that he has suffered from a foot disorder since military service. Instead, the Veteran has not explained why he believes his foot disorder is related to service when the first clinical symptoms of a possible foot disorder was 35 years after he left military service. Moreover, the Board notes that the Veteran submitted claims for other VA benefits prior to claiming the issues on appeal. Thus, the Veteran was aware of the VA benefits system, and had the Veteran been experiencing these conditions since service, it is intuitive that he would have submitted claims for the disorders at that time. There are no indications that the Veteran’s foot disorders have a nexus with his military service. Specifically, there are no treatment records establishing that the Veteran’s disorders are related to active duty or a service-connected disability, nor has any physician asserted that such a relationship exists. In fact, as noted above, the Veteran himself has not provided an explanation as to how his foot disorders were caused by his military service. While the Veteran believes his foot disorders are related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires advanced medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board reiterates that the preponderance of the evidence weighs against findings that any in-service injury, event, or disease occurred. Without any basis to suggest that the Veteran’s bilateral foot disorders are related to military service, the Board finds that the weight of the competent evidence does not attribute the disorders to military. In reaching the above conclusion, the Board also considered the doctrine of reasonable doubt. 38 U.S.C. § 5107(b). However, as the most probative evidence is against the claim, the doctrine is not applicable in this case. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a bilateral hand disorder is remanded. 2. Entitlement to service connection for a toes disorder is remanded. 3. Entitlement to service connection for chest pain is remanded. 4. Entitlement to service connection for hypertension is remanded. 5. Entitlement to service connection for a gastrointestinal disorder is remanded. 6. Entitlement to service connection for an anal condition, to include diverticulosis and hemorrhoids, is remanded. 7. Entitlement to service connection for keratoderma is remanded. 8. Entitlement to service connection for type 2 diabetes mellitus is remanded. 9. Entitlement to service connection for a head condition is remanded. In November 2012, the Veteran filed multiple service connection claims. These claims included service connection for a bilateral hand disorder, toes disorder, chest pain, hypertension, a gastrointestinal disorder, an anal condition, keratoderma, type 2 diabetes mellitus, and a head condition. These claims were addressed in a July 2013 rating decision. However, in the letter to the Veteran accompanying the decision, VA informed the Veteran that the July 2013 rating decision was a provisional decision. He could submit additional evidence within one year and the decision may be reconsidered. VA further informed the Veteran that if he wanted a final decision with appeal rights before the one-year provisional period ends, he must send VA a statement. VA did not finalize its decision until May 2016, approximately three years later. The Veteran filed a proper notice of disagreement in September 2016, but VA took no further action. As a statement of the case has yet to be issued regarding the above issues, and VA has not recognized the Veteran’s appeal of the above issues, the Board is obliged to take jurisdiction of these issues and remand them for the issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238, 240-41 (1999).   The matters are REMANDED for the following action: Send the Veteran and his representative a statement of the case that addresses the issues of service connection for a bilateral hand disorder, toes disorder, chest pain, hypertension, a gastrointestinal disorder, an anal condition, keratoderma, type 2 diabetes mellitus, and a head condition. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issues should be returned to the Board for further appellate consideration B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Borman, Associate Counsel