Citation Nr: 18153909 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 14-20 971 DATE: November 28, 2018 ORDER An initial rating in excess of 10 percent for a skin disability is denied. An initial rating of 10 percent, but no more, for a rectal disability, characterized as an anal fissure, prior to March 2, 2016, is granted. An initial rating in excess of 10 percent for a rectal disability, characterized as an anal fissure, as of March 2, 2016, is denied. Service connection for a left shoulder disorder is granted. Service connection for a right wrist disorder is granted. Service connection for a right thumb disorder is granted. Service connection for a prostate disorder, to include testicular pain and sterility, is denied. Service connection for a bilateral ankle disorder is denied. Service connection for an eye disorder is denied. Service connection for a disorder of the central nervous system is denied. Service connection for memory loss is denied. REMANDED Entitlement to service connection for a liver disorder, to include hemochromatosis and fatty liver disease, to include as secondary to and/or aggravated by a service-connected disability is remanded. Entitlement to service connection for diabetes, to include as secondary to and/or aggravated by a service-connected disability is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a heart disorder is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a respiratory disorder is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran’s skin disability is manifested by symptoms covering less than 5 percent of the exposed area and less than 20 percent of the entire body without intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. 2. Throughout the period on appeal, the Veteran’s rectal disability was characterized by diarrhea, loose stools, and some fecal leakage; however, moderate and persistent or frequently occurring leakage, or occasional involuntary bowel movements necessitating wearing a pad, have not been shown. 3. It is at least as likely as not that the Veteran’s left shoulder disorder had its onset during service and/or is otherwise etiologically related to service. 4. It is at least as likely as not that the Veteran’s right wrist disorder had its onset during service and/or is otherwise etiologically related to service 5. It is at least as likely as not that the Veteran’s right thumb disorder had its onset during service and/or is otherwise etiologically related to service. 6. Throughout the period on appeal, the Veteran does not have a diagnosis or a disability relating to a bilateral ankle disorder. 7. Throughout the period on appeal, the Veteran does not have a diagnosis or a disability relating to an eye disorder. 8. Throughout the period on appeal, the Veteran does not have a diagnosis or a disability relating to a disorder of the central nervous system. 9. Throughout the period on appeal, the Veteran does not have a diagnosis or a disability relating to memory loss. 10. Throughout the period on appeal, the Veteran does not have a diagnosis or a disability relating to prostate disorder. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for a skin disability have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.14, 4.118, Diagnostic Code (DC) 7806 2. The criteria for an initial rating of 10 percent, but no more, for a rectal disability, characterized as an anal fissure, prior to March 2, 2016, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.10, 4.14, 4.114, DC 7332. 3. The criteria for an initial rating in excess of 10 percent for a rectal disability, characterized as an anal fissure, as of to March 2, 2016, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.10, 4.14, 4.114, DC 7332. 4. The criteria for service connection for a left shoulder disorder are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309. 5. The criteria for service connection for a right wrist disorder are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309. 6. The criteria for service connection for a right thumb disorder are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309. 7. The criteria for service connection for a bilateral ankle disorder are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309. 8. The criteria for service connection for an eye disorder are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309. 9. The criteria for service connection for a disorder of the central nervous system are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309. 10. The criteria for service connection for memory loss are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309. 11. The criteria for service connection for a prostate disorder, to include testicular pain and sterility, are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1982 to February 1992. In January 2018, the Veteran was granted TDIU, effective May 12, 2017. Shortly thereafter, the Veteran filed a claim for an earlier effective date which was denied by the Regional Office (RO) in February 2018. The Veteran did not appeal this decision. Therefore, the issue of entitlement to an earlier TDIU effective date is not on appeal. Cf. Tyrues v. Shinseki, 23 Vet. App. 166, 176 (2009). The Board observes that the Veteran originally filed a claim for service connection for chronic symptoms, including pain, relating in part to his left shoulder, right wrist, right thumb, bilateral ankles, and left knee that were characterized by the RO as single disorder (joint pain). However, during the course of the appeal, the medical evidence of record indicates that the Veteran has separate and distinct mechanical disorders affecting his left shoulder, right wrist, right thumb, and left knee. Cf. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Thus, as reflected herein, given that these disorders can potentially receive separate ratings, the Board has separated these issues. Further, as the RO has specifically discussed and addressed whether or not the Veteran’s bilateral ankle, left shoulder, right wrist, and right thumb disorders are related to service (albeit in the context of “joint pain”), the Board has jurisdiction over these issues. Additionally, with respect to the issue of joint pain, the Board notes that the Veteran was granted service connection for fibromyalgia as a qualifying disorder under 38 C.F.R. § 3.317. As such, given that generalized joint pain is a symptom of fibromyalgia, the Board considers this to be a full grant of the benefits sought on appeal with respect to this issue. See 38 C.F.R. § 4.71a, Diagnostic Code 52025. The Board also notes that the Veteran initially filed claims for a liver disorder, fatty liver disease, and hemochromatosis. As these claimed disorders manifest with the same or similar symptomatology, the Board has recharacterized the issue and framed it broadly as a liver disorder, to include hemochromatosis and fatty liver disease. See Clemons, 23 Vet. App. 1. Similarly, the Board observes that the Veteran filed a claim for “testicular pain and sterility.” As the medical evidence indicates that the Veteran’s testicular pain may be caused by a prostate disorder, the Board has framed the issue broadly as a prostate disorder, to include testicular pain and sterility. See Id. Additionally, the Board notes that during the course of the appeal, the Veteran had urinary symptoms. However, to the extent his urinary symptoms are not related to the Veteran’s prostate/testicular disorder, the Board finds that this is a separate and distinct issue that is not on appeal. Moreover, to the extent the Veteran wishes to file a claim for a urinary disorder, this issue is referred to the RO. The Board also observes that the Veteran submitted additional relevant medical evidence that was not considered by the Regional Office (RO). However, as his substantive appeal was filed after February 2, 2013, a remand for initial RO consideration is not necessary. 38 U.S.C. § 7105. Increased Ratings The Veteran is seeking increased ratings for his skin and rectal disabilities. 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. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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. In cases where the Veteran’s claim arises from a disagreement with the initial evaluation following the grant of service connection, the Board shall consider the entire period of claim to see if the evidence warrants the assignment of different ratings for different periods of time during these claims a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999). 1. Entitlement to an initial rating in excess of 10 percent for a skin disability The Board notes that the Veteran’s skin disability was originally assigned a 10 percent rating for skin lesions under 38 C.F.R. § 4.118, DC 7806 (addressing dermatitis). Further, the Board observes that in April 2018, the RO granted the Veteran’s tinea pedis and tinea corporis service connection claims, and combined his skin disability ratings into a single 10 percent rating under DC 7806. The Board agrees that a single rating is appropriate given that the Veteran’s skin disabilities are rated based upon the percentage of involvement of the entire body and separate evaluations would be pyramiding. See 38 C.F.R. 4.14; M21-1, Part III, Subpart iv, 4.L.1.a. In evaluating the Veteran’s skin disabilities, the Board notes that during the appeal period, changes were made to 38 C.F.R. § 4.118, DC 7806, effective August 13, 2018. Importantly, VA’s intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. In this case, considering that the new post-August 2018 rating criteria limits the types of treatment that qualify for a higher rating, the Board determines that the old criteria are more favorable, and will rate the Veteran’s skin disabilities under the pre-August 2018 rating criteria. In order to warrant the next higher 30 percent rating for a skin disability, the evidence must demonstrate a skin disorder affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or for dermatitis or eczema that requires systemic therapy, such as corticosteroids or other immunosuppressive drugs, for a total duration of six weeks or more, but not constantly, during the past 12-month period. 38 C.F.R. § 4.118. After a review of the evidence of record, the Board determines that a rating in excess of 10 percent is not warranted. Specifically, in an April 2010 VA examination, the Veteran presented with an “intermittent” and “persistent” rash of his legs, thighs, and chest. The Veteran reported taking oral antifungal medical for three days at a time to treat his rash. On examination, the examiner observed multiple small rashes that affected less than 20 percent of his entire body and less than 5 percent of his exposed body. There was no scarring or disfigurement related to his condition. Additionally, while the Veteran used oral antifungal medication, the Board finds that there is not sufficient evidence that he used it for a total duration of six weeks or more during the past 12 months. Similarly, the Veteran’s most recent March 2018 VA examination reflects findings most consistent with a 10 percent rating. Here, the Veteran stated that “the only skin condition present today is athletes foot.” He also noted that he uses “creams and powders” for his eczema, ringworm, and athletes foot. On examination, the examiner determined that all of the Veteran’s skin conditions affected less than 5 percent of his entire body and less than 5 percent of his exposed body. There was no scarring or disfigurement related to his condition. Moreover, while the Veteran used topical creams and powders for 6 weeks or more during the prior year, this is not considered a corticoid steroid or immunosuppressive drug as the medication does not travel through the blood stream and/or affect multiple major body functions. Further, the Veteran’s treatment records do not support a higher rating based upon size of the skin disorder or the use of corticosteroids or other immunosuppressive drugs at any point during the time on appeal. Specifically, while the Veteran’s treatment records reflect that the Veteran had “severe” dermatitis, and occasionally took steroids, there was not sufficient evidence that he took steroids for at least 6 weeks in a 12-month period. Moreover, the December 2012, March 2013, December 2016 private treatment records did not indicate the Veteran had any skin abnormalities. Therefore, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran’s skin disorder on a schedular basis. The Board has also considered all potentially applicable diagnostic codes that rate his skin disorder. Of note, the Board has considered whether a higher rating is appropriate under DCs 7800 through 7805, which compensates for scarring. 38 C.F.R. § 4.118. However, the objective evidence medical evidence from the Veteran’s VA treatment and examination records do not reflect that the Veteran has any identifiable scarring related to his skin condition that would warrant a higher rating. 2. Entitlement to an initial compensable rating for a rectal disability, characterized as an anal fissure The Veteran’s rectal disorder, characterized as an anal fissure, has been assigned a noncompensable rating prior to March 2, 2016, and 10 percent thereafter, under 38 C.F.R. § 4.114, DC 7332. As a preliminary matter, the Board assigns an initial 10 percent rating for the entire period on appeal as the evidence, including the Veteran’s April 2010 VA examination, in conjunction with the Veteran’s statements, is at least in equipoise that his symptoms most closely approximated the criteria for a 10 percent rating. In order to warrant a 20 percent rating under this diagnostic code, the evidence must show occasional involuntary bowel movements necessitating the use of a pad. See Id. Here, the Board determines that a rating in excess of 10 percent is not warranted for any period on appeal. Specifically, at VA examinations in April 2010 and March 2018, while the Veteran reported bowel disturbances, there was no evidence that the Veteran was currently experiencing involuntary bowel movements, or used pads. Similarly, the Veteran’s private medical treatment records, including from April, June, and October 2016, do not reflect involuntary bowel movements or the use of pads or other appliances. Further, while the January 2017 private treatment records indicate that the Veteran has occasional fecal incontinence, there is no indication that he requires the use of a pad or appliance. Next, the Board has considered whether the Veteran could receive a higher rating under any other relevant diagnostic code. Specifically, as the March 2018 VA examiner determined that the Veteran had a prolapse of the rectum and fecal leakage, consideration has been given as to whether a higher rating could be assigned under DC 7334, which evaluates impairment from a prolapse. Pursuant to DC 7334, a 20 percent rating is warranted for moderate, persistent or frequently recurring prolapse. Nevertheless, there is no indication in the medical evidence, including the April 2010 and March 2018 VA examinations, that the Veteran’s rectum prolapse was moderate and persistently or frequently recurring. Therefore, a rating in excess of 10 percent for the entire period on appeal is not warranted. In arriving at this conclusion, the Board has also considered the Veteran’s statements that his skin and rectum disabilities are worse than the rating 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). 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 of his colon cancer residuals 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 skin and rectal disabilities has 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 these residuals are evaluated. The Board also finds that consideration for an extraschedular evaluation, a component of a claim for an increased rating, is not warranted. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). In considering whether an extraschedular rating may be warranted, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran’s level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. See Thun v. Peake, 22 Vet. App. 111 (2008). The evidence does not indicate that Veteran’s disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. Specifically, the Board has reviewed all of his relevant symptoms related to the issues on appeal, and concludes that there are no symptoms that were not able to be addressed by the applicable diagnostic codes. See Mittleider v. West, 11 Vet. App. 181 (1998). As such, the Veteran’s symptoms are not which are so unusual that they are outside the schedular criteria. Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran’s disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995).   Service Connection 3. Entitlement to service connection for a left shoulder disorder 4. Entitlement to service connection for a right wrist disorder 5. Entitlement to service connection for a right thumb disorder The Veteran asserts that his left shoulder, right wrist, and right thumb disorders were related to service. 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. After a review of the evidence, the Board concludes that the Veteran’s current left shoulder, right wrist, and right thumb disorders had their onset during service and/or is otherwise etiologically related to, including aggravated by, 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), 3.304, 3.307, 3.309. In this case, the Veteran’s service treatment records reflect numerous complaints of left shoulder pain during service that was diagnosed as bicipital tendonitis. Further, the post-service medical evidence, in conjunction with the Veteran’s credible statements, indicate that he has had left shoulder pain since service. Moreover, the April 2010 VA examination noted that the Veteran has intermittent bursitis that “appears” to be a continuation of his left shoulder tendonitis that was diagnosed during service. Moreover, the March 2018 VA examination revealed that the Veteran had degenerative joint disease in his left shoulder. As such, the Board finds that the evidence is at least in equipoise to support service connection. Next, with respect to the Veteran’s right wrist and right thumb disorders, the Board observes that the Veteran sustained numerous injuries to his right hand during service, to including hitting a wall and car windshield. The post-service medical evidence, including the Veteran’s April 2010 VA examination, indicates that he had pain in his right hand and thumb since service. Further, the examiner determined that the Veteran has pain and arthritis in his thumb and hand that was a result of his in-service hand fracture. Additionally, the Board takes notice of the fact that the Veteran is service-connected for a disorder of the right fingers that was also caused by his in-service right-hand injury. Therefore, the Board finds that the evidence is in relative equipoise to support service connection for these disorders. 6. Entitlement to service connection for a prostate disorder, to include testicular pain and sterility 7. Entitlement to service connection for a bilateral ankle disorder 8. Entitlement to service connection for an eye disorder 9. Entitlement to service connection for a disorder of the central nervous system 10. Entitlement to service connection for memory loss The Veteran asserts that his prostate, bilateral ankle, eye, respiratory, memory loss, and central nervous system disorders are related to service. As a preliminary matter, the Board concludes that the Veteran does not have a current diagnosis of these disorders for VA compensation purposes, and has not had a diagnosis of these disorders at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). In this case, the Board finds that after a thorough reading of the post-service evidence of record, including an April 2018 VA examination, as well as the Veteran’s treatment records, the evidence does not reflect a current diagnosis related to these disorders at any time during the period on appeal. Specifically, regarding a prostate disorder, including testicular pain and sterility, the Board notes that the Veteran had right testicle pain, prostatitis, and genital herpes during service. However, while the Veteran’s post-service treatment records reflect symptoms of “urinary trouble,” there is no evidence that the Veteran has a genital disorder, including the testicles and prostate. Of note, the Veteran’s May 2015 private treatment records reflect that he his testicles were normal. Similarly, the March 2018 VA examiner opined that while prostatitis is most likely the cause of voiding dysfunction, there is no evidence that the Veteran has a disorder affecting his genitals. Moreover, the examiner determined that there were no prostate, testicular or penile abnormalities, to include sterility. Additionally, to the extent the record indicates that the Veteran may have herpes that was incurred in service, the Board finds that the Veteran’s original claim for “right testicle” pain does not include a claim for herpes as the Veteran does not assert, and the record does not reflect that his herpes causes his testicular pain. The Board also notes that given that the Veteran is already service-connected for multiple skin disorders that consider his bodily rashes, it is unlikely that the Veteran would receive additional compensation based upon skin disfigurement. With respect to a bilateral ankle disorder, the Veteran did not have a diagnosis relating to this disorder at his April 2014 and April 2018 musculoskeletal examinations. Moreover, while the VA treatment records report the Veteran has a refractive error, the Board notes that congenital or developmental defects, such as a refractive error are not considered “diseases or injuries within the meaning of applicable legislation” and, hence, do not constitute disability for VA compensation purposes. See 38 C.F.R. § 3.303(c), 4.9. The Board also notes that the Veteran’s treating physician in October 2010 stated that he did not have an eye disorder. Additionally, regarding memory loss and a central nervous system disorder, while the Veteran reported related symptoms, there is no evidence that he has an actual diagnosed disorder related to these symptoms. In arriving at this conclusion, the Board acknowledges the Veteran’s assertions and belief that he has these disorders, however, he is not competent to provide a diagnosis in this case. Diagnosing a disorder is medically complex and requires specialized medical education and knowledge of the interaction between multiple systems in the body, as well as the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, to the extent the Veteran is competent to report pain, weakness, and limitation of motion, the Board acknowledges the holding in the United States Court of Appeals for the Federal Circuit in Saunders v. Wilkie, 2018 U.S. App. LEXIS 8467 (2018), which indicates that pain can constitute a “disability” under 38 U.S.C. § 1110. However, the medical evidence, including the April 2010 and March 2018 VA examinations, is not sufficient to demonstrate a disability for VA purposes. Moreover, the Veteran’s treatment records do not reflect sufficient functional limitation in his ankles to constitute a disability for VA purposes. Additionally, the Board notes that to the extent the Veteran’s symptoms may be related to an undiagnosed illness or a medically unexplained chronic multi-symptom illness (MUCMI) pursuant to 38 U.S.C. § 1117, the Veteran is already service-connected for a qualifying condition. Therefore, he is already receiving compensation for symptoms including joint pain, weakness, fatigability, etc. As such, it would be improper pyramiding to grant service-connection for a disorder that manifests with the same or similar symptomatology of a current service-connected disability. See 38 C.F.R. § 4.14. As such, the preponderance of the evidence is against a finding that the Veteran has a disability relating to his ankles, memory loss, central nervous system, eyes, and prostate at any point during the time on appeal. See 38 U.S.C. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992). REASONS FOR REMAND 1. Entitlement to service connection for a respiratory disorder is remanded. The Board observes that the medical evidence, including private treatment records from December 2014 and May 2017, indicates that the Veteran may have a diagnosis of sleep apnea. Nevertheless, given that the disability questionnaire provided to the March 2018 VA examiner was for respiratory disorders that did not include sleep apnea, it does not appear as if the examiner considered whether or not the Veteran has sleep apnea, and if so, if it was related to service. Therefore, a new opinion is necessary. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Entitlement to service connection for a left knee disorder is remanded. The Board notes that the Veteran initially filed a claim of service connection for a left knee disorder. In January 2018, the RO granted service-connection for “fibromyalgia (also claimed as left knee pain and fatigue).” As such, given that this issue was not listed in the most recent April 2018 supplemental statement of the case, it appears that the RO considered this to be a full grant of the benefits sought on appeal with respect to issue. Nevertheless, the Board finds that the medical evidence, including an October 2017 VA examination, reflect that the Veteran has a separate mechanical knee disorder. Additionally, the Board notes that the medical evidence, including the October 2017 VA examination, indicates that his left knee disorder may have been aggravated by his service-connected right knee disorder. Therefore, on remand, the RO should develop (to include obtaining a new VA examination) and adjudicate whether or not the Veteran is entitled to service-connection for a left knee disorder. 3. Entitlement to service connection for diabetes, to include as secondary to and/or aggravated by a service-connected disability is remanded. The Board observes that the Veteran submitted medical literature indicating a possible nexus between his diabetes and service-connected gastrointestinal disorder. However, while the Veteran was provided with a diabetes VA examination in March 2018, the examiner did not discuss or address if his diabetes were caused and/or aggravated by his gastrointestinal disability. As such, these opinions are inadequate and a new opinion is necessary. See Nieves-Rodriguez, 22 Vet. App. 295; Barr, 21 Vet. App. 303, 312. 4. Entitlement to service connection for a liver disorder, to include hemochromatosis and fatty liver disease, to include as secondary to and/or aggravated by a service-connected disability is remanded. 5. Entitlement to service connection for a heart disorder is remanded. 6. Entitlement to service connection for hypertension is remanded. The Board notes that the medical evidence, including the October, November, and December 2016 private treatment records and opinions from the Veteran’s treating physicians indicate that these disorders may be secondary to and/or aggravated by the Veteran’s diabetes. Therefore, the Board is unable to adjudicate these claims until the above development is completed. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). The matters are REMANDED for the following action: 1. Obtain all treatment records that are available from the VA Medical Center in Fairfield, Virginia, as well as from any VA facility from which the Veteran has received treatment since November 2017. If the Veteran has received additional private treatment, he should be afforded an appropriate opportunity to submit the medical records of such treatment. 2. Schedule the Veteran for a VA examination to determine the nature, extent, onset and etiology of his respiratory disorder (to include sleep apnea) diabetes, liver disorder (to include hemochromatosis and fatty liver disease), heart disorder, hypertension, and left knee disorder. The examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that these disorders ae etiologically related to the Veteran’s period of service, to include as secondary to and/or aggravated (permanently worsened beyond the natural progress of the disorder) by a service-connected disability. With respect to diabetes, the examiner must specifically consider the medical literature submitted by the Veteran which indicates a potential relationship between his service-connected gastrointestinal disorder and diabetes.   If the examiner cannot provide the requested opinion without resorting to mere speculation, he or she should provide a complete explanation stating why this is so. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Meyer, Associate Counsel