Citation Nr: 18154528 Decision Date: 12/03/18 Archive Date: 11/30/18 DOCKET NO. 16-37 970 DATE: December 3, 2018 ORDER Entitlement to service connection for erectile dysfunction is granted. Entitlement to an initial rating of 30 percent for service-connected gastroesophageal reflux disease (GERD) with clinical chronic gastritis is granted. Entitlement to an initial compensable rating for service-connected scar of the left knee is denied. Entitlement to a disability rating in excess of 30 percent for service-connected status post left knee injury with medial partial meniscectomy, chondromalacia patella and medical tibial plateau and instability is denied. Entitlement to an initial rating in excess of 70 percent for service-connected major depressive disorder is denied. Entitlement to an effective date prior to January 14, 2013 for the grant of service-connected for GERD is denied. Entitlement to an effective date prior to January 14, 2013 for the grant of service connection for scar, status post left knee injury with medial partial meniscectomy. is denied. Entitlement to an effective date prior to February 23, 2005 for the grant of service connection for major depressive disorder is denied. Entitlement to an effective date prior to May 2, 2011 for the grant of entitlement to a total disability rating based on individual unemployability (TDIU) is denied. Entitlement to an effective date prior to May 2, 2011 for entitlement to dependent's educational assistance is denied. Entitlement to special monthly compensation based on loss of use of a creative organ is granted. REMANDED Entitlement to a disability rating in excess of 10 percent for left knee osteoarthritis is remanded. Entitlement to SMC for loss of use of a left knee is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran’s current diagnosis of erectile dysfunction is caused by his service-connected major depressive disorder. 2. The Veteran’s GERD with clinical chronic gastritis is characterized by persistently recurring nausea, sleep disturbance, heartburn, epigastric burning sensation, dyspepsia, abdominal pain, pyrosis, and regurgitation, accompanied by substernal pain, which are productive of considerable impairment of health, but does not more nearly approximate material weight loss, hematemesis or melena with moderate anemia or other symptoms indicating severe impairment of health. 3. The evidence shows that the Veteran’s scar of the left knee is less than 6 square inches (39 square centimeters), not tender or painful, and does not result in any other disabling effects. 4. Service-connected status post left knee injury with medial partial meniscectomy, chondromalacia patella and medial tibial plateau and instability is rated at the maximum amount for knee instability throughout the relevant appeal period. 5. The symptoms and overall impairment caused by major depressive disorder do not more nearly approximate total occupational and social impairment at any time during the appeal period. 6. The claims file does not contain any communication or evidence received after the final December 2008 rating decision that denied entitlement to reopen entitlement to service connection for diverticulitis and service connection for a bowel disorder and prior to January 14, 2013, which could be interpreted as an informal or formal claim to reopen entitlement to service connection for a stomach disorder to include GERD. 7. The claims file shows that within the one-year period prior to January 14, 2014, it was not factually ascertainable that the Veteran first met the requirements for a separate noncompensable rating for scar, status post left knee injury with medial partial meniscectomy. 8. The claims file does not contain any communication or evidence received prior to February 23, 2005, which could be interpreted as an informal or formal claim for entitlement to service connection for a psychiatric disorder to include major depressive disorder. 9. The evidence shows that the Veteran’s service-connected disabilities did not preclude him from securing and following substantially gainful employment prior to May 2, 2011. 10. Prior to May 2, 2011, a permanent and total disability rating was not in effect. 11. The Veteran’s erectile dysfunction is service-connected. CONCLUSIONS OF LAW 1. The criteria for secondary service connection for erectile dysfunction are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310(a). 2. The criteria for an initial rating of 30 percent for service-connected GERD with clinical chronic gastritis are met. 38 U.S.C. § 1155; 38 C.F.R. § 4.114, Diagnostic Code 7399-7346. 3. The criteria for an initial compensable rating for service-connected scar of the left knee are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. 4. The criteria for a disability rating in excess of 30 percent for service-connected status post left knee injury with medial partial meniscectomy, chondromalacia patella and medical tibial plateau and instability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45.4.59, 4.68, 4.71a, Diagnostic Codes 5010, 5260, 5261, 5257 (2017). 5. The criteria for an initial rating in excess of 70 percent for service-connected major depressive disorder are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code 9434. 6. The criteria for an effective date prior to January 14, 2013 for the grant of service-connected for GERD are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 7. The criteria for an effective date prior to January 14, 2013 for the grant of a separate noncompensable rating for scar, status post left knee injury with medial partial meniscectomy are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 8. The criteria for an effective date prior to February 23, 2005 for the grant of service connection for major depressive disorder are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 9. The criteria for an effective date prior to May 2, 2011 for the grant of entitlement to a TDIU are not met. 38 U.S.C. § 1155, 5110; 38 C.F.R. §§ 3.341, 3.400, 4.1, 4.15, 4.16. 10. The criteria for an effective date prior to May 2, 2011 for entitlement to DEA benefits are not met. 38 U.S.C. §§ 1155, 3500, 3501, 5110; 38 C.F.R. §§ 3.1, 3.151, 3.340, 3.341, 3.400, 3.401. 11. The criteria for special monthly compensation based on loss of use of a creative organ are met. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350 (a)(1)(ii). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Army Reserves from November 1977 to 1993 with active duty from September 1990 to November 1990. This case is before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision. Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. 38 C.F.R. § 3.303. Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology for specific chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection for a claimed disability may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a). 1. Entitlement to service connection for erectile dysfunction. The Veteran contends that his current erectile dysfunction is caused by or aggravated by his service-connected depressive disorder to include medications prescribed to treat such disability. The Board concludes that the Veteran has a current diagnosis of erectile dysfunction that is caused by his service-connected major depressive disorder. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303(a), 3.310. An August 2014 VA examination reveals that the Veteran has a current diagnosis of erectile dysfunction. Regarding the issue of whether the Veteran’s erectile dysfunction is secondary to his service-connected major depressive disorder, the record contains conflicting medical opinions. In this regard, an August 2014 VA examiner determined that the Veteran’s erectile dysfunction is not at least as likely as not proximately due to nor the result of the Veteran’s service-connected disabilities. The examiner explained that the Veteran reported erectile dysfunction since approximately six or seven years ago; however, VA treatment records show he has been under treatment for depressive disorder back to 1999 with different anti-depressives. The examiner also explained that the Veteran currently used Zolpidem and Amitriptyline and erectile dysfunction was not reported as a side effect of these medications. The examiner concluded that since the antidepressive therapy predated the onset of erectile dysfunction, the Veteran’s erectile dysfunction is not likely related to the medications used for his mental condition. In contrast, in September 2018, a private physician provided the medical opinion that it is more likely than not that the Veteran’s erectile dysfunction is secondary to his service-connected major depressive disorder compounded by his medications used to treat his service-connected major depressive disorder. The physician’s rationale was that the Veteran is able to have an erection, just not maintain one and therefore, it is less likely to be an organic cause (such as hypertension) of his erectile disorder, and more likely a psychological cause of his erectile dysfunction. The physician asserted that depression plays a major contributing role as a cause of erectile dysfunction and included medical literature in support of this opinion. The physician also explained why he disagreed with the medical opinion provided by the August 2014 VA examiner. Specifically, the physician noted that Veteran’s medication used to treat his depression, to include Amitriptyline, does contribute to erectile dysfunction and included medical literature that supports his opinion. In this case, the Board finds that the September 2018 private medical opinion is more probative on the issue of whether the Veteran’s erectile dysfunction is caused by his service-connected depressive disorder. Specifically, the private physician provided a thorough rationale for her medical opinion based on the evidence of record, the lay statements provided by the Veteran, and medical literature. She explained in detail why she disagreed with the August 2014 VA examiner and provided medical literature that supported her rationale. In contrast, the August 2014 VA examiner did not include the medical literature he relied upon to determine that erectile dysfunction was not a reported side effect of the medication prescribed to treat the Veteran’s depressive disorder. After careful review of the evidence to include the aforementioned medical opinions, the Board finds no reason to accord more weight to the negative medical opinion over the positive medical opinion. Thus, the evidence is at least in equipoise with respect to whether erectile dysfunction is caused by the Veteran’s service-connected major depressive disorder and the Board resolves any reasonable doubt in favor of the Veteran. Accordingly, the Board finds that entitlement to service connection for erectile dysfunction is warranted. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). See also Fenderson v. West, 12 Vet. App. 119, 126 (1999) (applying this concept to initial ratings). It is the Board's responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an initial rating in excess of 10 percent for service-connected GERD with clinical chronic gastritis. Disabilities involving the digestive system are evaluated under the regulatory criteria found at 38 C.F.R. §§ 4.110- 4.114. The Veteran’s service-connected GERD with clinical chronic gastritis is currently rated as 10 percent disabling under the provisions of 38 C.F.R. § 4.114, Diagnostic Codes 7399-7346. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 7399 is used to identify disabilities of the digestive system that are not specifically listed in the schedule, but are rated by analogy to similar disabilities under the schedule. See 38 C.F.R. §§ 4.20, 4.27. The assignment of Diagnostic Code 7346 shows that the Veteran’s service-connected GERD with clinical chronic gastritis is rated as analogous to hiatal hernia. Under Diagnostic Code 7346, a 10 percent evaluation is assigned when there is evidence of two or more of the symptoms for the 30 percent evaluation of less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346. A 30 percent evaluation is assigned when there is evidence of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Ratings under diagnostic codes 7301 to 7329, 7331, 7342, and 7345 to 7358, are inclusive and may not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability so warrants. 38 C.F.R. § 4.114. Coexisting diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition, do not lend themselves to distinct and separate disability evaluations without resulting in unlawful pyramiding. 38 C.F.R. § 4.113. The Veteran underwent a VA examination in August 2014. He reported that he has experienced recurrent heartburn, dyspepsia, abdominal pain, epigastric burning sensation, several times per week. These symptoms are precipitated by medications that he takes to treat pain in his knee and back, asthma medication, and certain irritants in food. It is alleviated by taking antacids. He reported experiencing regurgitation several times per month and nausea twice per month. The examiner determined that the Veteran experienced four or more recurring episodes of gastritis that are not severe per year. The average duration of each episodes is less than a day. He experiences period ic abdominal pain that occurs at least monthly. He experiences transient nausea that occurs four or more times per year and that lasts less than one day. The examiner documented that the Veteran did not have any incapacitating episodes due to signs or symptoms of any stomach or duodenum condition. With respect to the Veteran’s GERD, the August 2014 VA examiner documented that the Veteran’s treatment included continuous medication to include Omeprazole, daily, Ranitidine at bedtime, TUMS as needed, and Gaviscon, as needed. The examiner noted that the Veteran had the following symptoms due to GERD: persistently recurrent epigastric distress, pyrosis, reflux, regurgitation, substernal pain, sleep disturbance caused by esophageal reflux, and nausea with a frequency of four or more times a year that last on average less than one day. There was no evidence of esophageal stricture, spasm of the esophagus, or an acquired diverticulum of the esophagus. The examiner provided the opinion that the Veteran’s esophageal conditions do not impact his or her ability to work. Based on the evidence of record, the most pertinent of which was discussed above, the Veteran’s GERD with clinical chronic gastritis most closely approximates a 30 percent disability rating. In this regard, the August 2014 VA examiner determined that the Veteran’s GERD is manifested by persistently recurrent epigastric distress with pyrosis, and regurgitation, accompanied by substernal pain. He also experiences persistently recurrent reflux, nausea, and sleep disturbance due to GERD. The Veteran reported experiencing the following symptoms associated with his GERD and gastritis: recurrent heartburn, dyspepsia, abdominal pain, epigastric burning sensation, several times per week, regurgitation several times per month, and nausea, approximately twice per month. Based on the foregoing, the Board finds that the overall evidence indicates that the symptoms of the Veteran’s GERD and chronic gastritis are productive of considerable impairment of health based on its severity, frequency, and duration. In finding that a 30 percent rating is warranted, the Board declines to grant a 60 percent rating. The August 2014 VA examiner did not report that the Veteran experienced weight loss, hematemesis, melena, or anemia. Furthermore, the examiner did not indicate that the Veteran’s symptoms of GERD or chronic gastritis resulted in severe impairment of health. Although the Veteran’s VA treatment records document that he sought treatment for GERD and chronic gastritis, the records reflect that it did not result in melena, hematemesis, or weight loss. Furthermore, the medical evidence of record shows that the Veteran does not have anemia. There is nothing in the medical or lay evidence of record that would indicate the Veteran’s GERD has caused material weight loss and hematemesis or melena with moderate anemia or other symptoms productive of severe impairment of health. Therefore, the criteria for a 60 percent disability rating are not met. 3. Entitlement to an initial compensable rating for service-connected scar of the left knee. The Veteran contends that he is entitled to a higher disability rating for his service-connected scar of the left knee. The Veteran’s scar of the left knee is currently rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7805. Under this diagnostic code, any disabling effect(s) that are not considered in a rating provided under diagnostic codes 7800-04 should be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. The evidence of record shows that the Veteran’s scar of the left knee does not result in any disabling effects. In this regard, the August 2014 VA examination noted that the Veteran had a surgical scar on his left knee related to the Veteran’s service-connected medial partial meniscectomy, chondromalacia patella and medical tibial plateau of the left knee. The examiner observed that the scar was not painful and/or unstable. The total area of the scar was not greater than 39 square centimeters. The Veteran does not contend, and the evidence does not otherwise show, that his left scar results in any disabling effects of the left knee. Under this diagnostic code, one or two scars that are unstable or painful warrant a 10 percent rating. A 20 percent disability rating is warranted for three or four scars that are unstable or painful. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over scar. 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1). With respect to whether the left knee scar warrants a compensable disability rating under an alternative diagnostic code, a 10 percent rating is warranted for scars, other than head, face, or neck, that are deep and nonlinear, when the area or areas encompass at least 6 square inches (39 square centimeters), but less than 12 square inches (77 square centimeters) under Diagnostic Code 7801. 38 C.F.R. § 4.118, Diagnostic Code 7801. A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Note (1) (2015). Diagnostic Code 7802 provides that scars, other than the head, face or neck, that are superficial and nonlinear are assigned a 10 percent rating when the area is 144 square inches (929 square centimeters) or greater. 3 8 C.F.R. § 4.118, Diagnostic Code 7802. Diagnostic Code 7804 provides that one or two scars that are unstable or painful warrant a 10 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7804. The preponderance of the evidence shows that the Veteran’s left knee scar is less than 6 square inches (39 square centimeters). The August 2014 VA examination documents that the Veteran’s left knee scar was not painful and/or unstable. Further, the Veteran has not asserted that the left knee scar is painful. Based on the foregoing, the Board concludes that the Veteran is not entitled to a higher disability rating under Diagnostic Codes 7801-02 and 7804. 4. Entitlement to a disability rating in excess of 30 percent for service-connected status post left knee injury with medial partial meniscectomy, chondromalacia patella and medical tibial plateau and instability. The Veteran’s service-connected osteoarthritis of the left knee is evaluated as 10 percent disabling under Diagnostic Code 5010-5060 for painful limited motion of the left knee. This issue will be discussed further in the remand section below. He is also in receipt of a separate 30 percent disability rating under Diagnostic Code 5257 for left knee instability. This diagnostic code provides that recurrent subluxation or lateral instability of the knee that is slight warrants a 10 percent disability. Moderate recurrent subluxation or lateral instability warrants a 20 percent disability rating and severe subluxation or lateral instability warrants a 30 percent disability rating. The words “slight,” “moderate” and “severe” are not defined in the VA Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “moderate” or “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. A 30 percent disability is the highest rating available under Diagnostic Code 5257 that evaluates recurrent subluxation or lateral instability of the knee. Thus, a disability rating in excess of 30 percent under Diagnostic Code 5257 for service-connected left knee instability is not warranted. 5. Entitlement to an initial rating in excess of 70 percent for service-connected major depressive disorder When evaluating a mental disorder, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126. The Veteran’s service-connected major depressive disorder is currently rated as 70 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9435 for unspecific depressive disorder. Depressive disorders are rated pursuant to the General Rating Formula for Mental Disorders. Id. Under the General Rating Formula for Mental Disorders, a 70 percent rating is prescribed for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is prescribed for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. The use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the Veteran’s social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). During the appeal the RO increased the Veteran’s rating for service-connected major depressive disorder from 50 percent to 70 percent, effective February 23, 2005. The medical evidence of record consists of VA treatment records, Social Security Administration disability records, and VA examinations dated in July 2011 and August 2014. Furthermore, the Veteran provided additional information about his anxiety disorder in written lay statements. The Board finds that this evidence, the most pertinent of which is summarized below, shows that the Veteran’s symptoms of major depressive disorder do not more closely approximate the requirements for a 100 percent disability rating of total occupational and social impairment at any point during the appeal. In this regard, the medical and lay evidence shows that the Veteran did not have gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. The Veteran also did not have other symptoms of similar severity and frequency. See VA examinations dated in July 2011 and August 2014 and VA treatment records dated in September 2005, November 2007, August 2008, April 2009, May 2010, March 2011, November 2011, April 2012, November 2013, and October 2014. Specifically, the VA treatment records document from September 2005 to November 2014 that the Veteran’s thought process was relevant, coherent, logical with no racing thoughts. He consistently denied experiencing auditory or visual hallucinations. The Veteran’s speech was spontaneous, coherent, and fluent. He was alert and oriented to person, time, and place. He had grossly intact memory, concentration, and attention throughout the appeal period. His appearance was consistently described as good grooming, good hygiene, and appropriately dressed. VA treatment records document that he had good eye contact and his behavior was cooperative. However, his VA treatment records consistently document him struggling with managing his anger and irritability. The July 2011 VA examination revealed that the Veteran reported a long history of depressed mood, anhedonia, and irritability. He denied hallucinations. The examination revealed that the Veteran’s thought process was unremarkable. He was oriented to time, place, and person. His attention was intact. The August 2014 VA examiner documented that the Veteran had depressed mood, chronic sleep impairment, mild memory loss, and disturbance of motivation and mood. He had adequate hygiene and he was cooperative. There was no evidence of psychomotor retardation or agitation. His speech was clear with appropriate volume, and goal directed. His mood was mildly depressed and affect appropriate with mood. He was in full contact with reality with no evidence of delusion or hallucinations. The Veteran was fully orient to person, place, and time. The evidence shows that the Veteran sought inpatient treatment in February 2007. He reported that for the last three weeks he had been unable to sleep. Earlier in the day, he lost it with a client at work and started throwing things, shouted at everyone, and a grabbed a sharp object trying to prick himself. The Veteran reported having self-harm ideas recently by driving recklessly and overdosing. He was discharged two days later. Other than the February 2007 incident of suicidal intent, the VA treatment records from September 2005 to November 2014 consistently document that the Veteran denied suicidal or homicidal ideation. Furthermore, the VA examinations in July 2011 and August 2014 also reveal that the Veteran did not have any suicidal or homicidal ideation. Thus, the Board finds that the Veteran’s symptoms of major depressive disorder does not result in persistent danger of hurting self or others. The lay and medical evidence reflects that the Veteran’s symptoms of a depressive disorder impacted his ability to work and his social relationships. In this regard, the Veteran is currently unemployed, in part, due to his depressive disorder. From July 2003 to November 2009 the Veteran worked as a Veteran Service Officer (VSO) for the Puerto Rico Office of the Veteran’s Advocate. He was laid off as a result of Public Law 7. The July 2011 VA examiner noted that the Veteran’s leisure pursuits included arts craft and gardening. The August 2014 VA examiner noted that the Veteran enjoyed being with friends and being active in church activities. The evidence shows that the Veteran was married three times. Thereafter, he had a longterm partner for six years that ended when she died. The August 2014 VA examination revealed that he was engaged since February 2014. He described his relationship with his fiancé as good. He is also the father of four adult children and he described his relationship as good. In light of the foregoing, the evidence of record reflects that neither the symptoms nor overall impairment caused by the Veteran’s major depressive disorder more nearly approximates total occupational and social impairment. Accordingly, a 100 percent disability rating for major depressive disorder is not warranted at any time during the appeal period. Effective Date Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim or a claim reopened after a final disallowance will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. A specific claim in the form prescribed by the Secretary of VA must be filed for benefits to be paid to any individual under the laws administered by VA. 38 U.S.C. § 5101(a). Prior to March 24, 2015, informal claims were recognized. Any communication or action, indicating an intent to apply for one or more VA benefits may be considered an informal claim. 38 C.F.R. § 3.155 (2014). An informal claim must identify the benefit sought. VA law provides that the effective date of an award of increased compensation, which include TDIU, shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if application is received within one year from such date; otherwise, the effective date will be the date of VA receipt of the claim for increase, or date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a), (b)(2); 38 C.F.R. § 3.400 (o); Hazan v. Gober, 10 Vet. App. 511 (1997); Harper v. Brown, 10 Vet. App. 125 (1997); VAOPGCPREC 12-98. 6. Entitlement to an effective date prior to January 14, 2013 for the grant of service-connected for GERD The Veteran asserts that he is entitled to an effective date earlier than January 14, 2013 for the grant of service-connection for GERD. Historically, the Veteran originally filed a service connection claim for stomach problems in October 1998. The RO denied service connection for diverticulitis on the basis that the evidence fails to establish a relationship between diverticulitis and medications prescribed to treat his service-connected left knee condition. The RO notified the Veteran of this decision in March 1999 at the Veteran’s then current address of record. The Veteran submitted additional evidence in support of his claim in May 1999. The RO continued the denial of service connection for diverticulitis on the basis that the additional evidence is negative for any evidence of diverticulitis and does not show that diverticulitis could be related to his service-connected left knee disability in a May 1999 rating decision. The RO notified the Veteran of this decision in June 1999 at the Veteran’s then current address of record. The Veteran did not appeal this decision. The record does not reflect that new and material evidence was received during the one-year appeal period following the notice of the May 1999 rating decision and no additional, relevant service records, warranting reconsideration of the claim, was received at any time thereafter. See 38 C.F.R. § 3.156(b), (c). Thus, the May 1999 rating decision is final. The Veteran filed another service connection claim for diverticulitis and bowel condition in March 2008. In a December 2008 rating decision, the RO denied the Veteran’s request to reopen his service connection claim for diverticulitis, because the evidence submitted was not new and material. The RO also denied service connection for a bowel disorder on the basis that the Veteran has a current diagnosis of GERD that was neither incurred in nor was caused by service. The RO notified the Veteran of this decision in December 2008 at the Veteran’s then current address of record. There is no evidence of written communication from the Veteran expressing dissatisfaction or disagreement with the December 2008 rating decision within one year of said decision. Moreover, in this case, no exception to finality applies. The record does not reflect that new and material evidence was received during the one-year appeal period following the notice of the December 2008 rating decision and no additional, relevant service records, warranting reconsideration of the claim, was received at any time thereafter. See 38 C.F.R. § 3.156(b), (c). Thus, the December 2008 rating decision is final. The Veteran submitted another claim for service connection for a stomach disorder that the RO received on January 14, 2013. In September 2014, the RO granted service connection for GERD, effective January 14, 2013, the date the RO received the Veteran’s most recent service connection claim for a stomach disorder. The record reflects that the Veteran called the RO on January 14, 2013 to make a service connection claim for a stomach condition secondary to medication take for his service-connected conditions. There is no other communication or action from the Veteran in the claims file indicating that he had an intent to apply for service connection for a stomach disorder after the December 2008 rating decision and prior to January 14, 2013. According to the applicable regulation, the effective date of the Veteran’s allowance is January 14, 2014; the date the RO first received any communication indicating an intent to reopen his service connection claim for a stomach disorder. See 38 C.F.R. § 3.400(q)(2) and (r). Thus, the assignment of an earlier effective date for the grant of service connection for a stomach disorder is not warranted. In this case, the nature of the Veteran’s theory of entitlement with respect to this issue is unclear. The Veteran and his attorney have been given multiple opportunities to submit or identify evidence or arguments in support of this claim, but apparently chose not to do so. The Veteran’s attorney is reminded that it is a claimant’s responsibility to support a claim for VA benefits, including submitting or specifically identifying relevant evidence and alleging specific errors of fact of law. See 38 U.S.C. §§ 5107(a), 7105(d)(5). Counsel are expected to present arguments they deem material and relevant to their clients’ cases. See e.g. Andrews v. Nicholson, 421 F.3d 1278, 1282 (Fed. Cir. 2005) (pro se pleadings, not those of counsel, are entitled to a sympathetic reading). 7. Entitlement to an effective date prior to January 14, 2013 for the grant of service connection for scar, status post left knee injury with medial partial meniscectomy. The Veteran asserts that he is entitled to an effective date earlier than January 14, 2013 for the grant of service connection for scar of the left knee. A review of the record shows that the RO received the Veteran’s original service connection claim for a left knee disorder in September 1993. In March 1995, the RO granted service connected for a left knee disorder, effective September 24, 1993. The Veteran appealed this decision in April 1995; however, he did not submit a substantive appeal in response to the October 1995 statement of the case. The Veteran submitted a claim for an increased rating for his left knee disability in October 1998. The RO denied the Veteran’s claim in a March 1999 rating decision. The Veteran submitted additional evidence and the RO continued the denial in a May 1999 rating decision. The Veteran filed another increased rating claim for the left knee in December 2003. In March 2004, the RO granted a 30 percent disability rating for his service-connected left knee disability. The Veteran appealed this decision in March 2004; however, he did not submit a substantive appeal in response to the April 2004 statement of the case. The Veteran submitted an increased rating claim for the left knee in February 2005. The May 2005 rating decision increased the disability rating of the left knee to 40 percent. The Veteran did not submit a notice of disagreement with respect to the portion of the May 2005 rating decision that granted an increased rating for the left knee. The Veteran filed another increased rating claim for the left knee in March 2008. In a December 2008 rating decision, the RO denied an increased rating for the left knee. The RO notified the Veteran of this decision in December 2008 at the Veteran’s then current address of record. The Veteran did not appeal this decision. A November 2009 VA joints examination of the knee was associated with the claims file. Thereafter, in a December 2009 rating decision, the RO decreased the Veteran’s left knee disability from 40 percent to 30 percent and granted a separate 10 percent rating for left knee osteoarthritis. The RO notified the Veteran of this decision in December 2008 at the Veteran’s then current address of record. The Veteran did not appeal this decision. The Veteran did not submit any correspondence or evidence indicating an increase in the Veteran’s left knee disability from the December 2009 rating decision to January 14, 2013. On January 14, 2013, the RO received the Veteran’s claim for an increased rating for his service-connected left knee disability as part of his claim for TDIU and SMC for loss of use of the left knee. In the September 2014 rating decision, the RO granted service connection for scare of the left knee with a noncompensable rating, effective January 14, 2014. The separate noncompensable rating for scar of the left knee was awarded during the pendency of the Veteran’s appeal for an increased rating for his left knee disability. As the separate noncompensable rating for scar of the left knee was awarded as part of the Veteran’s increased rating claim for his service-connected left knee disability, the earliest possible effective date for the award of the separate disability rating for scar of the left knee is January 14, 2012. See 38 U.S.C. § 511 (a) and 38 C.F.R. § 3.400(o)(2) (If, the ascertainable increase precedes receipt of the formal or informal claim, then the effective date is the date of ascertainable increase, if the claim is received within one year thereof). As regards to the date of entitlement, the term “date entitlement arose” is not defined in the current statute or regulation. However, the Court has interpreted it as the date when the claimant met the requirements for the benefits sought. This is determined on a “facts found” basis. See 38 U.S.C. § 5110(a); see also McGrath v. Gober, 14 Vet. App. 28, 35 (2000). It is important to note that an effective date generally can be no earlier than the “facts found.” DeLisio v. Shinseki, 25 Vet. App. 45 (2011). These “facts found” include the date the disability first manifested and the date entitlement to benefits was authorized by law and regulation. See generally 38 C.F.R. § 3.400. For instance, if a claimant filed a claim for benefits for a disability before he actually had the disability, the effective date for benefits can be no earlier than the date the disability first manifested. Ellington v. Peake, 541 F.3d 1364, 1369-70 (Fed. Cir. 2008). Pertinent to this case, the Board acknowledges that the Veteran’s increased rating claim for his left knee was received on January 14, 2013. The Veteran does not assert and the medical evidence does not otherwise show that the scar of the left knee was factually ascertainable within the one-year prior to the Veteran filing his increased rating claim for the left knee on January 14, 2013. Accordingly, an assigned effective date for the separate noncompensable rating for scar of the left knee prior to January 14, 2013 is not warranted and the Veteran’s claim must be denied. See 38 C.F.R. §§ 3.114 (a), 3.400(p). 8. Entitlement to an effective date prior to February 23, 2005 for the grant of service connection for major depressive disorder. The RO granted service connection for unspecified depressive disorder and assigned a 50 percent disability rating, effective January 14, 2013 in a September 2014 rating decision. Thereafter, the RO granted an initial rating of 70 percent for major depressive disorder, effective February 23, 2005 in an October 2014 decision noting that a clear and unmistakable error was made in the September 2014 rating decision with respect to assigning an initial rating and effective date. In September 2015, the RO received the Veteran’s noticed of disagreement to the September 2014 rating decision with respect to the effective date of the award and evaluation of the service-connected depressive disorder. The record reflects that the RO received a statement from the Veteran on February 23, 2005 informing the RO that he requested service connection for a nervous condition. There is no other communication or action from the Veteran in the claims file indicating that he had an intent to apply for service connection a psychiatric disorder to include a nervous condition or depressive disorder prior to February 23, 2005. In this case, the nature of the Veteran’s theory of entitlement with respect to this issue is unclear. The Veteran and his attorney have been given multiple opportunities to submit or identify evidence or arguments in support of this claim, but apparently chose not to do so. The Veteran’s attorney is reminded that it is a claimant’s responsibility to support a claim for VA benefits, including submitting or specifically identifying relevant evidence and alleging specific errors of fact of law. See 38 U.S.C. §§ 5107(a), 7105(d)(5). Counsel are expected to present arguments they deem material and relevant to their clients’ cases. See e.g. Andrews v. Nicholson, 421 F.3d 1278, 1282 (Fed. Cir. 2005) (pro se pleadings, not those of counsel, are entitled to a sympathetic reading). In conclusion, the controlling laws and regulations state that an award of disability compensation will be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(b)(2)(i). The February 23, 2005 correspondence is the earliest document in the record that reveals the Veteran intended to file a claim for service connection for a psychiatric disorder. Thus, February 23, 2005, the date the Veteran filed his original service connection claim for a nervous condition, is the appropriate effective date. Here, the evidence of record, viewed in conjunction with the pertinent laws and regulations, provide no basis for an award of service connection for depressive disorder prior to February 23, 2005. The Board notes, the nature of the Veteran’s theory of entitlement with respect to this issue is unclear. The Veteran and his attorney have been given multiple opportunities to submit or identify evidence or arguments in support of this claim, but apparently chose not to do so. The Veteran’s attorney is reminded that it is a claimant’s responsibility to support a claim for VA benefits, including submitting or specifically identifying relevant evidence and alleging specific errors of fact of law. See 38 U.S.C. §§ 5107(a), 7105(d)(5). Counsel are expected to present arguments they deem material and relevant to their clients’ cases. See e.g. Andrews v. Nicholson, 421 F.3d 1278, 1282 (Fed. Cir. 2005) (pro se pleadings, not those of counsel, are entitled to a sympathetic reading). 9. Entitlement to an effective date prior to May 2, 2011 for the grant of entitlement to a total disability rating based on individual unemployability. The Veteran contends that he is entitled to an effective date no later than November 7, 2009 for the grant of a TDIU. Specifically, the Veteran’s attorney notes that the March 2015 rating decision cites that the Social Security Administrations records establish May 2, 2011 as the Veteran’s last day of employment. She argues that this is incorrect and the Social Security Administration evaluation report dated in May 2011 states that the Veteran’s last date of employment was November 7, 2009. The Veteran filed a claim for service connection for a psychiatric disorder in February 2005. The Veteran’s service connection claim was continuously adjudicated thereafter, including in the September 2014 rating decision, in which the RO granted service connection for an unspecified depressive disorder. The Veteran appealed the initial rating assigned for unspecified depressive disorder. As the Veteran asserts that he is entitled to a TDIU prior to May 2, 2011, in part, due to his service-connected unspecified depressive disorder, the issue of entitlement to a TDIU was raised as part of the initial rating claim. Total disability will be considered to exist when there is present any impairment of mind or body, which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (2016). If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341 (2016). In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15 (2016). If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that he has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16 (a). For the purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. It is provided further that the existence or degree of non-service connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service-connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the Veteran unemployable. Marginal employment shall not be considered substantially gainful employment. For purposes of 38 C.F.R. § 4.16, marginal employment generally shall be deemed to exist when a veteran’s earned annual income does not exceed the amount established by the U.S. Department of Commerce as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16 (a). Prior to May 2, 2011, the Veteran was service-connected for the following: major depressive disorder, status post left knee left knee injury with medial partial meniscectomy, chondromalacia patella and medical tibial plateau and instability, evaluated as 30 percent disabling, left knee osteoarthritis evaluated as 10 percent disabling, right knee disability, evaluated as 10 percent disabling. The combined rating for these service-connected disabilities from February 23, 2005 is 90 percent. Accordingly, the Veteran met the schedular percentage requirements for entitlement to a TDIU prior to May 2, 2011. See 38 C.F.R. § 4.16(a). With respect to the issue of TDIU, the crucial inquiry for the Board is not whether the Veteran is able to pursue his profession of choice, or indeed any particular job. Instead, the Board must inquire as to whether the Veteran can secure and follow a substantially gainful occupation in a more general sense. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The fact that a veteran is unemployed is not enough. It must be determined that his service-connected disorders without regard to his advancing age make him incapable of performing the acts required by employment. Id. The overall evidence of record demonstrates that the Veteran’s service-connected disabilities did not prevent him from obtaining and maintaining a substantially gainful occupation prior to May 2, 2011. In this regard, the Veteran stated in the August VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, that the date he last worked full time was in November 2009 and that was also the date that he became too disabled to work. He reported that he worked full time from July 2003 to November 2009 as a Veteran Service Officer (VSO) for the Puerto Rico Office of the Veteran’s Advocate. The Veteran also reported in the May 2011 Social Security Report that he stopped working November 6, 2009. In contrast, VA treatment records and July 2011 VA examination report document that the Veteran worked full-time in 2010 and at least in part during 2011. Specifically, a November 2009 VA psychiatric treatment record shows that the Veteran reported that he lost his job as a VSO on November 6, 2009 as part of the layoffs due to Public Law 7. He indicated that he planned to go back to school to complete a master’s degree in business administration and human resources. In a June 2010 VA treatment record, the Veteran reported that he had a new job where he works as part of a Federal Program that was based on helping veterans find work. An October 2010 VA treatment record noted that the Veteran status post laminectomy on August 2010 and that he was requesting a medical reevaluation to return to work. VA treatment records dated in December 2010 and January 2010 documented that the Veteran reported that he worked for the Department of Labor of Puerto Rico in the veteran service department. The VA mental health examiner in July 2011 recorded that the Veteran was currently employed fulltime at the Department of Labor. Time lost from work was 28 weeks in the past twelve months due to his medical complaints. The examiner later clarified that the Veteran reported that he was unable to work since March 2011 after undergoing back surgery. A July 2011 VA joint and back examination also documented that the Veteran was currently employed fulltime in customer service with the Department of the Labor, but time lost from work was 28 weeks due to his back condition. A Social Security Disability Determination dated in September 2015 determined that the Veteran became disabled on May 1, 2011 due to disease of the joints and disorders of the back. Here, the Board finds the Veteran’s contemporaneous statements as to his employment documented in the VA treatment records and the July 2011 VA examinations are more persuasive and probative than the later statements made in connection with his application for TDIU or his application for Social Security disability benefits. See Fed. R. Evid. 803(4) (recognizing that statements made for the purpose of medical treatment generally are reliable); see also Pond v. West, 12 Vet. App. 341, 345 (1999) (interest may affect the credibility of testimony). In this regard, the Veteran’s statements as to employment in the VA treatment records were made when medical treatment was being rendered and they were made to ascertain the Veteran’s then-state of mental health. Thus, the Board finds that the medical history reported by the Veteran to a medical professional in seeking treatment for a medical problem is credible. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Accordingly, the preponderance of the evidence shows that the Veteran worked fulltime prior to May 2, 2011. Moreover, there is no indication that this work was marginal in nature, i.e., that the Veteran’s income did not exceed the relevant poverty threshold or that the job was in a protected environment, as the Veteran did not so indicate either in a written statement or on a VA Form 21-8940. As the preponderance of the evidence shows that the Veteran was employed full-time prior to May 2, 2011 and the Veteran does not contend or the evidence otherwise show that this employment should be considered marginal, the Board concludes that the Veteran’s service-connected disabilities did not prevent him from obtaining and maintaining substantially gainful employment prior to May 2, 2011. The benefit of the doubt doctrine is therefore not for application and entitlement effective date prior to May 2, 2011 for the grant of TDIU is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 10. Entitlement to an effective date prior to May 2, 2011 for entitlement to dependent’s educational assistance (DEA) The Veteran contends that he is entitled to an effective date prior to May 2, 2011 for DEA benefits. Basic eligibility for DEA exists if a veteran has a permanent, total service-connected disability. 38 U.S.C. §§ 3500, 3501. A total disability may be assigned where the veteran’s service-connected disabilities are rated 100 percent disabling under the rating schedule, or if the veteran is unemployable due to service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341. Permanence of total disability will be taken to exist when such impairment is reasonably certain to continue throughout the life of the disabled person. 38 C.F.R. § 3.340(b). In this case, the effective date for the award of DEA benefits is May 2, 2011, the same date as the award of TDIU. As discussed above, the Board finds that the Veteran is not entitled to an effective date prior to May 2, 2011 for the award of TDIU. DEA benefits may not be awarded prior to the effective date of an award of a permanent and total disability rating. Therefore, the Veteran is not entitled to an effective date earlier than May 2, 2011, for entitlement to DEA benefits. 38 U.S.C. §§ 3501, 3510. SMC 11. Entitlement to special monthly compensation based on loss of use of a creative organ VA provides special monthly compensation (SMC) if a veteran, as a result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs. 38 U.S.C. § 1114(k). Entitlement to SMC based on loss of use of a creative organ can also be granted based on erectile dysfunction. 38 C.F.R. § 3.350(a)(1)(ii). In light of the grant of service connection for erectile dysfunction, the Board also grants SMC for loss of use of a creative organ. REASONS FOR REMAND 1. Entitlement to a disability rating in excess of 10 percent for left knee osteoarthritis is remanded. With respect to the Veteran’ increased rating claims for left knee osteoarthritis, a VA examination of the Veteran’s knees was conducted in August 2014. The U.S. Court of Appeals for Veterans Claims (Court) has held that 38 C.F.R. § 4.59 requires VA examination to include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). The Court has also recently held that that before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner must “elicit relevant information as to the Veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the Veteran’s functional loss due to flares based on all the evidence of record, including the Veteran’s lay information, or explain why she could not do so.” Sharp v. Shulkin, 29 Vet. App. 26 (2017). In this case, the VA examination report does not include the information necessary as required by Correia and Sharp. Accordingly, the Veteran must be provided with a new VA examination to determine the current nature and severity of his service-connected left knee osteoarthritis that includes the information required in Correia and Sharp. 2. Entitlement to SMC for loss of use of a left knee. The Veteran is seeking SMC for loss of use of the left foot/leg due to his service-connected left knee disability. Accordingly, this issue is inextricably intertwined with the Veteran’s increased rating claim for osteoarthritis of the left knee that is being remanded. Thus, adjudication of the claim for SMC for loss of use of the left foot/leg will be held in abeyance pending the adjudication of increased rating claim for osteoarthritis of the left knee. The matters are REMANDED for the following action: Schedule the Veteran for an appropriate VA examination to determine the current nature and severity of his left knee osteoarthritis. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. All findings should be reported in detail. The examiner should identify all left knee pathology found to be present. The examiner should conduct all indicated tests and studies, to include range of motion studies. The joints involved should be tested in both active and passive motion, in weight-bearing and non weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Berry, Counsel