Citation Nr: 18155865 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 16-45 996 DATE: December 6, 2018 ISSUES 1. Whether new and material evidence has been submitted to reopen the claim of service connection for a heart disability, as secondary to service-connected pre-pyloric ulcer with antrum scarring and hiatal hernia. 2. Whether new and material evidence has been submitted to reopen the claim of service connection for a liver disability with hepatitis C. 3. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression, to include as secondary to service-connected lumbosacral strain, prepyloric ulcer, bilateral hearing loss disability, and hemorrhoids. 4. Entitlement to service connection for sleep apnea, also claimed as sleep disorder, to include as secondary to service-connected residuals of lumbosacral strain. 5. Entitlement to service connection for a skin disability, claimed as Stevens Johnson syndrome. 6. Entitlement to service connection for a right leg disability, to include as secondary to service-connected residuals of lumbosacral strain. 7. Entitlement to an evaluation in excess of 40 percent for residuals of lumbosacral strain. 8. Entitlement to an evaluation in excess of 30 percent for pre-pyloric ulcer with antrum scarring and hiatal hernia. 9. Entitlement to an evaluation in excess of 10 percent for hemorrhoids. 10. Entitlement to a total disability rating based on individual unemployability (TDIU). ORDER New and material evidence sufficient to reopen the claim of service connection for a heart disability, as secondary to service-connected pre-pyloric ulcer with antrum scarring and hiatal hernia has not been received, and the application to reopen the claim is denied. New and material evidence sufficient to reopen the claim of service connection for a liver disability with hepatitis C has not been received, and the application to reopen the claim is denied. Entitlement to service connection for sleep apnea, also claimed as sleep disorder, to include as secondary to service-connected residuals of lumbosacral strain and claimed depression is denied. Entitlement to service connection for a skin disability, claimed as Stevens Johnson syndrome is denied. Entitlement to service connection for a right leg disability, to include as secondary to service-connected residuals of lumbosacral strain is denied. Entitlement to an evaluation in excess of 40 percent for residuals of lumbosacral strain is denied. Entitlement to an evaluation in excess of 30 percent for pre-pyloric ulcer with antrum scarring and hiatal hernia is denied. Entitlement to an evaluation in excess of 10 percent for hemorrhoids is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, claimed as depression, to include as secondary to service-connected lumbosacral strain, prepyloric ulcer, bilateral hearing loss disability, and hemorrhoids, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. A July 1998 rating decision originally denied service connection for a heart disability. The Veteran did not file a Notice of Disagreement or submit new and material evidence within one year. The July 1998 rating decision became final. 2. A September 2009 rating decision revisited the issue of service connection for a heart disability and considered the new issue of entitlement to service connection for a liver disability with hepatitis C. The rating decision denied reopening the heart disability claim, and denied service connection for a liver disability with hepatitis C. The Veteran did not file a Notice of Disagreement or submit new and material evidence within one year. The September 2009 rating decision became final. 3. Later in September 2009, the Veteran submitted a lay statement referencing his heart. The RO construed this in part as a new application to reopen his claim for service connection for a heart disability. In January 2010, he clarified this to include a new theory of entitlement of secondary service connection. 4. In an April 2010 rating decision, the Veteran’s claim for service connection for a heart disability now claimed as secondary to pre-pyloric ulcer with antrum scarring and hiatal hernia was revisited and ultimately not reopened. The Veteran did not file a Notice of Disagreement (NOD) or submit new and material evidence within one year. The April 2010 rating decision became final. 5. The heart and liver issues were both later revisited in a March 2012 rating decision, which denied reopening both claims. This appeal followed. 6. Additional new evidence received since the unappealed April 2010 rating decision for a heart disability as secondary to the service-connected disability of pre-pyloric ulcer with antrum scarring and hiatal hernia, and September 2009 rating decision concerning liver problems with hepatitis C, is cumulative of evidence previously of record at the time of the prior final denials. It does not cure the critical evidentiary defects that existed at the time of the prior denials, and does not raise a reasonable possibility of substantiating the claims. 7. Sleep apnea, also claimed as sleep disorder, was not incurred in or aggravated by service, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 8. The Veteran does not have a disability of the skin or mucous membranes, including Stevens Johnson syndrome. 9. The Veteran does not have a right leg disability. 10. Any claimed leg disability is already encompassed by the rating for service-connected radiculopathy of the left lower extremity associated with residuals of lumbosacral strain. 11. Residuals of lumbosacral strain is manifested by 50 degrees of flexion and 45 degrees of flexion after repetitive use testing, with Intervertebral Disc Syndrome (IVDS) with no incapacitating episodes in the past 12 months, and no ankylosis. 12. Pre-pyloric ulcer with antrum scarring and hiatal hernia is manifested by persistently recurrent epigastric distress, pyrosis, reflux, sleep disturbance caused by reflux occurring about 3 times per year for a period of 10 days or more, nausea occurring 4 or more times per year lasting 10 days or more, and vomiting 4 or more times per year. 13. Hemorrhoids is manifested by large external hemorrhoids, irreducible, and excessive redundant tissue; with no fissures or fistulas. CONCLUSIONS OF LAW 1. The August 2010 rating decision denying the Veteran ’s application to reopen his claim for service connection for a heart disability is now final. 2. The evidence received since the April 2010 rating decision is not new and material, and the claim is not reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The September 2009 rating decision denying service connection for a liver disability with hepatitis C is now final. 4. The evidence received since the September 2009 rating decision is not new and material, and the claim is not reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 5. Sleep apnea, also claimed as sleep disorder, to include as secondary to service-connected residuals of lumbosacral strain, was not incurred in or aggravated by service, is not proximately due to, the result of, or aggravated by service connected disease or injury, and is not otherwise attributable to service. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 6. A skin disability claimed as Stevens Johnson Syndrome was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 7. A right leg disability was not incurred in or aggravated by service, is not proximately due to, the result of, or aggravated by residuals of lumbosacral strain, and is not otherwise related to service. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 8. The criteria for an evaluation in excess of 40 percent for residuals of lumbosacral strain have not been met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.14, 4.3, 4.4, 4.45, 4.59, 4.7, 4.71a, Diagnostic Code 5237 (2017). 9. The criteria for an evaluation in excess of 30 percent for pre-pyloric ulcer with antrum scarring and hiatal hernia have not been met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.114, 4.14, 4.3, 4.7, Diagnostic Code 7304-7346 (2017). 10. The criteria for an evaluation in excess of 10 percent for hemorrhoids have not been met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.114, 4.14, 4.3, 4.7, Diagnostic Code 7336 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1970 to November 1973. This matter is before the Board of Veterans Appeals (Board) on appeal from March 2012 and August 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that the scope of a mental health disability claim includes any mental health disability that could reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. As a threshold matter, an October 2011 rating decision previously denied service connection for post-traumatic stress disorder (PTSD), also claimed as anxiety attacks. The Veteran did not file an Notice of Disagreement (NOD) or submit new evidence with respect to this issue. It became final. The current issue before the Board claimed as depression was first considered by way of an August 2013 rating decision. In other words, before the Board is a distinct claim. In light of Clemons, Board has recharacterized the appeal as encompassing the issue on the title page. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran was sent a detailed January 20, 2012 VCAA letter informing him of the additional information that would be helpful in substantiating his claims. The Veteran and his attorney submitted a January 25, 2017 Brief in Response to 90 Day Letter (Brief) in which they waived RO review of additional evidence. They requested review by the Board. The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Finality of Service Connection Claims 1. Whether new and material evidence has been received to reopen the claim of service connection for a heart disability, as secondary to service-connected pre-pyloric ulcer with antrum scarring and hiatal hernia. 2. Whether new and material evidence has been received to reopen the claim of service connection for a liver disability with hepatitis C. A review of the procedural and evidentiary history is instructive. By way of background, a July 1998 rating decision originally denied service connection for a heart disability. The Veteran did not file a Notice of Disagreement or submit new and material evidence within one year. The July 1998 rating decision became final. Next, the Veteran filed a new informal application in January 2009 to reopen the claim for service connection for a heart disability and for service connection for a liver disability. A September 2009 rating decision revisited the issue of service connection for a heart disability and considered the new issue of entitlement to service connection for hepatitis C. The rating decision denied reopening the heart disability claim, and denied service connection for a liver disability with hepatitis C. The Veteran did not file a Notice of Disagreement or submit new and material evidence within one year. The September 2009 rating decision became final. Later in September 2009, the Veteran sent VA a Statement in Support of Claim principally for tinnitus, the stomach, and back, but also referencing filing a claim regarding his heart. He reported, “[I]f I don’t catch my breath right my heart goes 100 miles an hour, so I’m filing on my Heart once again.” Based on his wording, this was construed by the RO as a separate, new application to reopen the previously denied claim for service connection for a heart disability. Not long thereafter, the Veteran expanded his theory of entitlement by way of a January 2010 Statement in Support of Claim. In the January 2010 Statement in Support of Claim, the Veteran clarified, “On my heart condition, my hiatal hernia, when I have an attack it causes my heart to increase its beating…” Next, in an April 2010 rating decision, the Veteran’s claim for service connection for a heart disability now claimed as secondary to pre-pyloric ulcer with antrum scarring and hiatal hernia was revisited and ultimately not reopened. The Veteran did not file a Notice of Disagreement or submit new and material evidence within one year. The April 2010 rating decision became final. The Veteran filed new applications to reopen the previously denied service connection claims. Specifically, VA received an application to reopen the previously denied claim for service connection for a heart disability in October 2011, and in December 2011 for the liver disability associated with hepatitis C. The Veteran was sent a January 20, 2012 development letter requesting him to provide new and material evidence and notifying him of the critical evidentiary defects necessary to substantiate his claims for service connection. The issues were both later revisited in a March 2012 rating decision, which denied reopening both claims. The rating decision found that the Veteran lacked a present heart disability, and that there was no nexus between a liver disability, including hepatitis C, and service. The Veteran through his attorney filed a Notice of Disagreement (NOD) in August 2012. The Veteran through his attorney perfected his appeal in December 2016. If new and relevant evidence is presented or secured with respect to a supplemental claim, the Secretary shall readjudicate the claim taking into consideration all of the evidence of record. 38 U.S.C. § 5108 (a). A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The United States Court of Appeals for Veterans Claims (Court) interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which “does not require new and material evidence as to each previously unproven element of a claim.” See id. The Board would note that regardless of how the RO (or the Board in a prior denial) ruled on the question of reopening, the Board must re-decide that matter on appeal. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) (reopening after a prior Board denial) and Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (reopening after a prior unappealed RO denial). Evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence was not previously presented to the Board. See Anglin v. West, 203 F.3d 1343 (2000). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). At the time of the March 2012 rating decision, the reason for the denial remained that the Veteran lacked evidence of current heart disability, and lacked a nexus between a liver disability including hepatitis C and service. In short, there were no post service findings that would justify heart disability. There was also still no nexus between any liver disability, later diagnosed as hepatitis C, and service. Although some of the evidence submitted is new, it is not material as it does not relate to an unestablished fact necessary to substantiate the claim, and does not raise a reasonable possibility of substantiating the claim. Additional evidence submitted since the September 2009 and April 2010 rating decisions is cumulative of the evidence of record at the time of the last prior final denials. For example, even though treatment records showing diagnostic impressions of and treatment for liver disability may be considered new, they are not considered material. They do not show evidence of a nexus. The Veteran’s lay statements and claims regarding his heart rate are also conclusory in terms of diagnosing a disability. First, in the April 2010 rating decision, the Veteran lacked a current heart disability. New and material evidence sufficient to reopen the claim has not been submitted. The added evidence, in pertinent part, consists of lay history. There is no new evidence showing that the Veteran has a current disability, and it follows that there is still no evidence that cures this critical evidentiary defect that existed at the time of the prior decision. Although the Veteran and his attorney have submitted several lay statements, the Veteran is not shown to be competent to render an opinion diagnosing a heart disability. His theory of entitlement is unsupported and the medical evidence does not provide a new basis for the claim. And although evidence must be presumed credible for purposes of deciding it’s materiality, it does not have to be presumed competent. And although the Veteran would be presumed credible in stating what a physician had told him for the purpose of determining materiality, such is not the case here. In that regard, the Veteran was sent a January 20, 2012 development letter requesting that he submit additional evidence to substantiate his claim. Moreover, the Veteran and his attorney received numerous rating decisions and an October 2016 Statement of the Case (SOC). Meanwhile, a VA treatment record from August 1, 2016 shows, “HEART: Is regular.” The heart does not appear in a contemporaneous problem list. Additional VA treatment records are substantially the same. Since then, several years have passed, during which time the Veteran and his attorney had time to cure the critical evidentiary defect that has existed since the July 1998 original rating decision. The Board observes that in the absence of proof of a current disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, VA has been unable to verify that the Veteran has a heart disability, and he continues to offer only conclusory statements. The Board therefore finds that the evidence is cumulative of evidence already of record at the time of the prior denial, and the claim is not reopened. See 38 C.F.R. § 3.156 (a). Second, regarding the liver disability diagnosed as hepatitis C, at the time of the September 2009 rating decision, the reason for the denial remained because the Veteran’s liver disability was not attributable to service. Hepatitis C was not shown to have been incurred or aggravated in service. In other words, there were post service findings that would justify disability. However, there was still no nexus. Although some of the evidence submitted is new, it is not material as it does not relate to an unestablished fact necessary to substantiate the claim. Additional evidence received since the September 2009 rating decision is cumulative of the evidence of record at the time of the last prior final denial. For example, VA treatment records showing diagnostic impressions of hepatitis C are considered new, but they are not considered material. An August 1, 2016 Hepatitis Clinic Consult Result shows that the Veteran presented for his first visit with that particular doctor by way of a referral. He reported that he was not sure when he was first diagnosed with hepatitis C. The VA treatment records shows: Noted patient has positive HEPCAB with positive HCV QUAL in 2003. No data for HCV genotyping found in the lab data. The last viral count was drawn in 2014 which showed HCV RNA 400,000. Pt reports no past history of injection/intranasal drug use (not even one time experiment), no blood transfusions, known sexual partner (s) with HCV infections, no hemodialysis, no history of incarceration, no known sexual partners with hep C infection, no body piercing. Patient reports placement of tattoo in 1967 on his left arm but states he did it himself. In sum, the evidence does not notate that a liver disability manifest in service or is otherwise attributable to service. Regarding the heart, his theory of entitlement does not provide a basis for the claim. The Board therefore finds that the evidence is cumulative of evidence already of record at the time of the prior final denials, and the claims are not reopened. See 38 C.F.R. § 3.156 (a). The preponderance of the evidence is against the claims. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection To establish service connection a Veteran must generally show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 3. Entitlement to service connection for sleep apnea, also claimed as sleep disorder, to include as secondary to service-connected residuals of lumbosacral strain The Board incorporates its discussion from the sections above by reference. By way of background, the Service Treatment Records (STRs) include a January 1971 Report of Medical History. The Veteran denied frequent trouble sleeping and frequent or terrifying nightmares. An October 1973 Report of Medical Examination from separation disclosed a clinically normal evaluation of the head, face, neck, and scalp, nose, sinuses, mouth and throat, and lungs and chest. An August 2010 VA psychiatric examination shows, “I can comment with confidence that the Veteran ’s sleep difficulty is not caused by or the result of psychiatric or mental health issues such as anxiety or depression.” Ongoing VA treatment records show that sleep apnea was identified by way of a September 28, 2010 sleep study associated with complaints of daytime sleepiness, frequent snoring, frequent arousals, daytime fatigue, and restless legs. The Veteran filed his claim for service connection for sleep apnea in September 2011. He reported that he was worn out with everything going on. He had a Fentanyl patch for pain. Next, the Veteran was afforded several November 2011 VA examinations. The VA examiner noted that sleep apnea was identified in September 28, 2010 by a sleep study. The VA examiner remarked, “He states he ‘tries’ to use the CPAP every night, but he takes it off because he can’t sleep well with it. He states, ‘I’m trying to use it; it seems like it pumps too much air’. He denies being able to consistently tolerate the CPAP.” The VA examiner opined that sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner reasoned, “Obstructive sleep apnea is caused by an obstruction with breathing interfering with oxygenation. When the individual tries to breathe, any air that squeezes past the blockage can cause loud snoring. It is typically due to anatomy, being overweight, or having some type of obstructive condition impairing breathing (even such as enlarged tonsils).” The VA examiner further opined, “It is not related to his back pain or the pain medication and the type of sleep apnea that can be related to being on narcotic pain medications is central sleep apnea, but he didn’t have this type of sleep apnea on sleep study findings.” Related to this finding, the Board observes that having responded to a broad question regarding the potential relationship between the two disabilities, the medical opinion rendered encompasses all possible theories of entitlement for secondary service connection. In other words, whether under a theory of sleep apnea being proximately due to, the result of, or aggravated by residuals of lumbosacral strain, the VA examiner’s answer of “not related” implicitly addressed these theories of entitlement. The Veteran filed his Notice of Disagreement (NOD) in August 2012. An August 13, 2012 VA Primary Care Note shows, “backache has not filled fentanyl since Mar 2012, currently he says pain in the back is only 5/10, says this happens only when he initially tries to stand and once he starts walking pain improves significantly, will not renew opiates.” Additional VA treatment records are substantially the same. The Veteran through his attorney perfected his appeal in December 2016. A January 2017 Sleep Apnea Disability Benefits Questionnaire (DBQ) from Dr. H. S. shows that the Veteran has had sleep apnea since September 28, 2010. It shows, “His inability to use the continuous positive airway pressure (CPAP) as prescribed causes him to be excessively sleepy during the day and requires him to have to nap.” Dr. H. S. rendered a private medical opinion. The private medical opinion begins with, “It is my opinion that it is as likely as not that the veteran’s obstructive sleep apnea is caused and permanently aggravated by the opioid medication used for his service connected back and depressive disorder.” Dr. H. S. goes on to describe VA treatment records showing Fentanyl use starting in 2008, though he claims that it continues to the present day. Next, the medical opinion concludes, “After review of the veterans claims file and medical records, I feel it is as likely as not his opioid medication use and depressive disorder have caused and permanently aggravated obstructive sleep apnea.” In the January 2017 Brief, the Veteran through his attorney avers that he is entitled to specifically direct service connection for obstructive sleep apnea. By way of background, sleep apnea is defined as transient periods of cessation of breathing during sleep. The two primary types are central sleep apnea and obstructive sleep apnea. See Dorland’s Illustrated Medical Dictionary, 118 (31st ed. 2007). Obstructive sleep apnea is defined as sleep apnea resulting from collapse or obstruction of the airway with the inhibition of muscle tone that occurs during REM sleep. Id. The Veteran is competent to relate what he has been told by a professional. He is also competent to report that he had difficulty sleeping in service. The Veteran is also competent to report his symptoms and observations of sleep apnea. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Here, the most probative evidence is the contemporaneous treatment records, including the Service Treatment Records (STRs), which show that sleep apnea was not manifest in service. In other words, although the Veteran later complained of difficulty sleeping several decades after discharge, sleep apnea was not identified or manifest during service. The most probative evidence is the STRs, VA treatment records, and November 2011 VA examination with medical opinion establishing a remote onset of sleep apnea several decades after discharge. VA treatment records show that sleep apnea was not diagnosed until September 28, 2010. The VA examiner reviewed the entire claims file, and opined that the condition claimed was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner also rendered a negative nexus opinion regarding secondary service connection. The VA examiner explained that the Veteran did not have the type of sleep apnea on sleep study findings that would be related to narcotic pain medications. The VA examiner noted other factors. The Board finds this to be highly probative. In the January 2017 Brief, the Veteran contends that he is entitled to direct service connection for sleep apnea. We have found that this is not warranted. The Veteran through counsel also submitted a January 2017 private medical opinion that discusses a secondary theory of entitlement. The Board finds that this is entitled to diminished probative weight, and that secondary service connection is therefore also not warranted. First, it does not contain a determinative medical opinion regarding direct service connection. It does not show that the Veteran was examined in person. It shows that Fentanyl is used up until the present day, which is inconsistent with the contemporaneous VA treatment records. Ongoing treatment records, including the related DBQ, show that the Veteran complained of being sleepy during the day, although he did not use his CPAP designed to alleviate such symptoms. The private medical opinion does not address this possible issue with patient compliance. The medical opinion notes depression, for which the Veteran is not service connected. With respect to the November 2011 VA medical opinion, the Board finds that it is based upon sound reasons and bases. The VA examiner provided a negative nexus opinion for secondary service connection. The medical opinion included a consideration of the date of onset of the disease entity, which has been substantially consistent with the Veteran’s own lay reporting and evidence he has submitted through counsel. Indeed, VA’s duty to assist includes providing an adequate examination when such an examination is indicated. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Once VA provides an examination, it must be adequate or VA must notify the Veteran why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An examination is adequate if it “takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one.” Barr, 21 Vet. App. at 311 (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). An examination must be based upon consideration of the Veteran’s prior medical history and examinations. Stefl, 21 Vet. App. at 123. Consequently, we find the November 2011 VA medical opinion to be adequate for the purposes of rendering this decision. In addition, we note that neither the Veteran nor his attorney have alleged any deficiencies in developing this claim in this regard. Turning to the Veteran’s own lay opinion, we find that it warrants less probative value (regarding identifying a potential disease entity and a relationship between disease entities) when compared with the objective medical evidence of record. The Board has also considered the Veteran ’s statements regarding his symptoms. However, the record establishes that he did not have the characteristic manifestations necessary to identify the disease entity in service, and the remote onset of sleep apnea is unrelated to in-service events. The medical evidence as to etiology is far more probative and credible than his lay statements. In sum, under a direct or secondary theory of entitlement, the most probative evidence shows that sleep apnea is not related to service, and is less likely than not proximately due, the result of, or aggravated any service connected disability. Consequently, service connection for sleep apnea is not warranted. In reaching this conclusion, the Board finds that the preponderance of the evidence is against this claim. As such, the benefit of the doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for Stevens Johnson syndrome 5. Entitlement to service connection for a right leg disability, to include as secondary to service-connected residuals of lumbosacral strain The Board incorporates its discussion from the sections above by reference. By way of background, the Veteran’s Service Treatment Records (STRs) disclosed a clinically normal evaluation of the lower extremities, neurologic system, and skin, lymphatics. The Veteran filed a claim for service connection for bilateral leg disability in May 2010. He reported problems with the nerves in his legs or muscles. It was getting to where it hurt to walk on his left leg. In September 2011, the Veteran filed another Statement in Support of Claim referencing several disabilities, including the bilateral legs and knees. He reported that he can’t stand for 15 minutes because his legs and knees were hurting like never before. By way of background, an October 2011 rating decision granted service connection for radiculopathy of the left lower extremity, and deferred a rating on the right leg. In October 2011, VA received correspondence showing that the Veteran would like to file a claim for Steven Johnson Syndrome. He reported that his doctor had him “on Dylanton (sic) for years.” A November 2011 VA back examination shows a notation of, “There was some mention of him possibly having right leg radiculopathy but he denies this was ever the case. He does complain of right knee problems when asked out right leg concerns (see knee DBQ for information).” At the contemporaneous November 2011 VA knee examination, the Veteran reported, “He states his right knee bothers him sometimes but it is a lot less than the left. He denies any known injuries and this just started earlier in 2011. He states it is similar to what he first experienced in the left knee. It ‘cracks and pops on occasion and ‘it is just starting.’ He denies having mentioned this to his VA PCP (no record of these complaints in his CPRS VA PCP office notes).” The remarks show, “He tells me that the right knee problem is what is meant by ‘right leg condition’ on his claim. He denies any symptoms of right leg radiculopathy.” Next, the VA examiner rendered a medical opinion. The VA examiner clarified: There is no evidence of right leg radiculopathy I think the question that should have been asked is if the left leg radiculopathy complaints are due to the residuals of lumbosacral back strain. Thus it is less likely than not that his right leg radiculopathy is related to his lumbosacral spine (since there is no evidence of right leg radiculopathy). However I do think it is as least as likely as not that his left leg radiculopathy is related to his lumbosacral spine condition. The Veteran was sent a January 20, 2012 development letter informing him of what was needed to fully substantiate his claims for service connection. The Veteran filed his timely Notice of Disagreement (NOD) in August 2012. VA treatment records are substantially the same, and show impressions of low back pain with reports of radiculopathic symptoms in the left lower extremity. See, e.g. August 2016 VA Radiology General Note with Addendum. The Veteran contends that he is entitled to service connection for a right leg disability and Stevens Johnson Syndrome. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to relate what he has been told by a professional. The Veteran is not competent to render a medical diagnosis of Steven Johnsons Syndrome. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board finds the lack of objective medical evidence as to the existence and diagnosis for any current right leg disability to be the highly probative, as explained by the November 2011 VA examiner. The VA examiner attributed the Veteran ’s reported leg pain to the left leg, for which he is service-connected. The Veteran also reported symptoms and a theory of entitlement consistent with these findings. This is consistent with the ongoing VA treatment records. There is no probative evidence ot the contrary. The Board observes that neither the Veteran nor his attorney have alleged otherwise or specifically requested any additional development of this issue. The Board also finds that the only evidence of Steven Johnsons Syndrome is by way of the Veteran’s conclusory statement advanced in support of his claim. Similarly, to the extent that he asserts that he has a skin disability, such theory is unsupported by the weight of the evidence. The Veteran was sent a development letter, and the Veteran and his attorney have had several years to show evidence of disability. In sum, we find the lack of objective medical evidence as to the existence and diagnosis for any current right leg or skin disability to be probative. Consequently, service connection for a right leg and a skin disability is not warranted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992 Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching these conclusions, the Board finds that the preponderance of the evidence is against the claims. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability ratings have not been previously staged. As discussed below, uniform evaluations are still warranted. 6. Entitlement to an evaluation in excess of 40 percent for of residuals of lumbosacral strain The Board incorporates its discussion from the sections above by reference. The Veteran asserts that he has a painful back disability, particularly when standing up. Residuals of lumbosacral strain is currently evaluated at 40 percent disabling pursuant to Diagnostic Code (DC) 5237, which pertains to loss of motion of the spine. 38 C.F.R. § 4.71a (2017). The Schedule for Rating Criteria mandated that disabilities of the spine under Diagnostic Codes 5235 to 5243 will be evaluated under a General Rating Formula for Diseases and Injuries of the Spine. This General Rating Formula assigns disability ratings with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by the residuals of the injury or disease. A 40 percent rating requires evidence of unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is for assignment upon a showing of unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a. A note after the General Rating Formula for Diseases and Injuries of the Spine specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate Diagnostic Code. Note (2) to the General Rating Formula explains that for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The criteria for Intervertebral Disc Syndrome (IVDS) also potentially apply. Under the rating criteria, IVDS may be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or otherwise based upon the frequency and severity of its incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The specific formula for IVDS provides: If there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks, a 40 percent rating is warranted; and where there are incapacitating episodes with a total duration of at least 6 weeks during the past 12 months, the assignment of a maximum 60 percent rating is warranted. Note (1) to the rating criteria provides that an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71, for Intervertebral Disc Syndrome. The Board must also consider a veteran’s pain, swelling, weakness, and excess fatigability when determining the appropriate disability rating for a disability using the limitation of motion diagnostic codes. 38 C.F.R. §§ 4.40, 4.45; See Johnson v. Brown, 9 Vet. App. 7, 10 (1996); DeLuca v. Brown, 8 Vet. App. 202 (1995). By way of background, the Veteran was afforded a November 2011 VA back examination. Upon clinical examination, the thoracolumbar spine had the following range of motion: flexion was 50 degrees, extension was 20 degrees, right lateral flexion was 20 degrees, left lateral flexion was 20 degrees, right rotation was 20 degrees, and left rotation was 25 degrees. The combined range of motion was 155 degrees. The thoracolumbar spine had the following range of motion after repetitive use due to pain: flexion was 45 degrees and left rotation was 20 degrees. The combined range of motion was additionally reduced to 145 degrees. No other changes due to repetitive motion were noted. X-ray findings showed arthritis. The Veteran had Intervertebral Disc Syndrome (IVDS), but with no incapacitating episodes over the past 12 months due to IVDS. Years later, a VA treatment record from June 24, 2015 shows: Spoke with the veterna (sic) on the phone, he has chronic low back and left knee pain,reports no radiculopathic pattern, numbness or new weakness, bladddser/bowel changes. (sic) He says back pain is for 40 years and left knee pain for 2 years.he says he has recently quit drinking few months ago. Will start tylenol, he agreed, also advised PT,he wants to defer that. (sic) veteran to come to clinic for any worsening or new symptoms, consider MRI if tylenol and PT do not help (sic). Additional VA treatment records are substantially the same. The Veteran seeks higher evaluation for residuals of lumbosacral strain, which is currently rated as 40 percent disabling under Diagnostic Code 5237. The current rating contemplates flexion of 50 degrees, reduced to 45 degrees with repetitive motion. In order to have a higher rating, there must be forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine or, intervertebral disc syndrome with incapacitating episodes with a total duration of at least 6 weeks during the past 12 months. That is not the case here, as the most probative evidence does not show that his symptoms are accompanied by such limited motion or incapacitating episodes. Here, the most probative evidence are the findings of the November 2011 VA examiner, presenting a detailed picture of the Veteran’s disability. Residuals of lumbosacral strain is most closely approximated by the current 40 percent rating based upon forward flexion of the thoracolumbar spine to 30 degrees or less, and with painful motion upon examination. See 38 C.F.R. § 4.71a, Diagnostic Code 5237. Moreover, the Veteran’s disability picture is not so severe as to warrant a higher rating, or even to necessarily warrant the current 40 percent rating. Objective medical evidence did not show forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine or, intervertebral disc syndrome with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. Indeed, at the November 2011 VA examination, forward flexion was to 50 degrees and 45 degrees with repetitive use due to pain, with no incapacitating episodes in the past 12 months. Nevertheless, we will not disturb the current 40 percent evaluation. Alternatively, in order to substantiate a higher evaluation, the evidence must indicate unfavorable ankylosis of the entire thoracolumbar spine. Here, ankylosis has not been assessed. There is no probative evidence of the functional equivalent of ankylosis. The provisions of 38 C.F.R. §§4.40 and 4.45 concerning functional loss due to pain, fatigue, weakness, or lack of endurance, incoordination, and flare-ups, as cited in DeLuca v. Brown, 8 Vet. App. 202 (1995), have been considered and do not result in a higher rating. There is no probative evidence to the contrary. There is no doubt to resolve. Consequently, an evaluation in excess of 40 percent for residuals of lumbosacral strain is not warranted. 7. Entitlement to an evaluation in excess of 30 percent for pre-pyloric ulcer with antrum scarring and hiatal hernia The Board incorporates its discussion from the sections above by reference. The Veteran asserts that he has feelings of his stomach burning and vomits for no reason. Pre-pyloric ulcer with antrum scarring and hiatal hernia is currently rated as 30 percent disabling under Diagnostic Code (DC) 7304-7346, which pertains to the digestive system. 38 C.F.R. § 4.114. (2017). 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 assigned rating. DC 7346 is for hiatal hernia. Under DC 7346, an evaluation of 30 percent is warranted for 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. DC 7304 is for ulcer, gastric. No specific evaluation criteria are provided for gastric ulcers. By way of background, a May 2010 Statement in Support of claim shows that the Veteran reported waking up choking on his own vomit. A July 2010 Statement in Support of Claim shows that he reports having a hiatal hernia. An August 2010 Statement in Support of Claim shows that the Veteran reported that he has a weak stomach. He vomits for no reason. His stomach burns like fire. The Veteran was afforded November 2011 VA examinations. A gastric ulcer and gastroesophageal reflux disease (GERD) were identified. The Veteran reported that GERD was under control. He had occasional mild symptoms including reflux, regurgitation, transient nausea, and rare dysphagia of solid, dry foods. These symptoms were approximately three times per year, and were not indicated to be severe. They lasted for less than one day. An August 2012 VA treatment record shows, “GERD Currently not taking PPI, advised to quit drinking.” An August 27, 2014 VA treatment record shows that the Veteran would restart Prilosec which he had stopped taking for two months, in order to treat GERD like symptoms. A VA treatment record from March 10, 2015 shows “GERD stable on PPI.” Next, the Veteran was afforded a September 2016 VA examination. Upon clinical examination, the VA examiner rendered a diagnosis of gastroesophageal reflux disease (GERD). Symptoms included persistently recurrent epigastric distress; pyrosis; reflux; sleep disturbance caused by reflux occurring about 3 times a year for a period of 10 days or more; nausea occurring 4 or more times a year lasting 10 days or more; and vomiting 4 or more times per year. Additional VA treatment records are substantially the same. The Veteran seeks higher evaluation for pre-pyloric ulcer with antrum scarring and hiatal hernia, which is currently rated as 30 percent. DC 7304-7346; 38 C.F.R. § 4.114. (2017). The current rating contemplates persistently recurrent epigastric distress; pyrosis; reflux; sleep disturbance caused by reflux occurring about 3 times a year for a period of 10 days or more; nausea occurring 4 or more times a year lasting 10 days or more; and vomiting 4 or more times per year. In order to have a higher rating, there must be symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. The most probative evidence is the contemporaneous VA treatment records and findings of the VA examiners. We also acknowledge the Veteran’s lay reports of vomiting and choking, and the frequency of these episodes as reported at the VA examinations. In the instant case, the symptoms do not squarely meet the 30 percent evaluation, however, this evaluation most closely approximates the severity of the Veteran’s disability. In addition, the VA examinations and treatment records show possible improvement, including with medication, and are not productive of “persistently recurrent epigastric distress” for the current 30 percent rating. The most probative evidence also does not show that his symptoms are accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Nevertheless, we will not disturb the current 30 percent evaluation. Indeed, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It follows that the Veteran’s symptoms are not of the frequency or severity to warrant the next higher rating. There is no doubt to resolve. Consequently, a rating in excess of 30 percent for pyloric ulcer with antrum scarring and hiatal hernia is not warranted. 8. Entitlement to an evaluation in excess of 10 percent for hemorrhoids The Board incorporates its discussion from the sections above by reference. The Veteran asserts that he has hemorrhoids. Hemorrhoids are currently rated as 10 percent disabling under DC 7336. 38 C.F.R. § 4.114. (2017). Under DC 7336, a 10 percent evaluation is assigned for external or internal hemorrhoids, large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent evaluation is assigned for external or internal hemorrhoids, with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, DC 7336 (2016). By way of background, the Veteran was afforded a November 2011 VA examination. The VA examiner noted that a 1999 flexible sigmoidoscopy showed, “large hemorrhoids.” He reported that these banded in 1999 and “things have been better since then.” The Veteran reported that he occasionally sees a little bit of wiping blood, but the last time was approximately eight months to one year ago. The Veteran reported that he was significantly better since he had a banding procedure. The VA examiner indicated that the Veteran had mild or moderately severe hemorrhoids. The VA examiner noted small or moderate external hemorrhoids. There were no fissures or fistulas. Next, VA treatment records show that the Veteran underwent a colonoscopy in October 2014. The results show, “Multiple small and large-mouthed diverticula were found in the entire colon. Non-bleeding internal hemorrhoids were found during retroflexion and were moderate. The exam was otherwise without abnormality.” The Veteran was most recently afforded a September 2016 VA examination. Upon clinical examination, large external hemorrhoids, irreducible external hemorrhoids, and excessive redundant tissue were identified. Hemorrhoids are currently assigned a 10 percent rating. The 10 percent rating contemplates large external hemorrhoids, irreducible, and excessive redundant tissue. In order to have a higher evaluation, there must be persistent bleeding with secondary anemia or fissures. The Veteran contends that he is entitled to an evaluation in excess of 10 percent for hemorrhoids. The Veteran is competent to report external bleeding. He is competent to report the results of a colonoscopy, as reported to him by medical professionals. However, hemorrhoids have not caused considerable impairment of health. Here, the most probative evidence is the contemporaneous treatment records and the results of the September 2016 VA examination. The September 2016 VA examination notably showed large external hemorrhoids. This was worse than the small or moderate external hemorrhoids noted at the November 2011 VA examination. Nevertheless, the 10 percent rating most closely approximates the Veteran ’s disability picture. There is no persistent bleeding with secondary anemia or fissures. The October 2014 VA colonoscopy revealed moderate, non-bleeding hemorrhoids. In sum, the Veteran does not have the degree of impairment that would warrant a higher rating. Although we acknowledge the Veteran ’s belief that he is entitled to a higher rating, we are bound by the rating criteria for this specific disability. There is no probative evidence to the contrary. Consequently, a rating in excess of 10 percent for hemorrhoids is not warranted. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching these conclusions, the Board finds that the preponderance of the evidence is against the claims. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression, to include as secondary to service-connected lumbosacral strain, prepyloric ulcer, bilateral hearing loss disability, and hemorrhoids, is remanded. The Board incorporates its discussion from the sections above by reference. A remand is necessary for additional development. As a threshold matter, an October 2011 rating decision previously denied service connection for post-traumatic stress disorder (PTSD), also claimed as anxiety attacks. The current issue has been broadened under Clemons. Before the Board is a distinct new claim for service connection for depression, exclusive of the prior October 2011 final denial. By way of background, the Veteran was afforded an August 2010 VA examination. The VA examiner did not find a current psychiatric disability. Next, the Veteran filed a new supplemental claim for service connection for depression in August 2012. The August 2013 rating decision denied service connection for depression. An October 2013 medical opinion by Dr. H.-G. showed a diagnosis of depressive disorder not otherwise specified (NOS). The Veteran denied a history of heavy drinking and substance abuse. A related October 2013 private medical opinion shows that depression is more likely than not secondary to service-connected lumbosacral strain, prepyloric ulcer, bilateral hearing loss disability, and hemorrhoids. There is no indication that the claims file was reviewed. In November 2013, the Veteran filed his Notice of Disagreement (NOD). The Veteran through counsel clarified his theory of entitlement specifically as one of secondary service connection. The Veteran through counsel cited the recent October 2013 medical opinion by Dr. H.-G. The Veteran perfected his appeal in September 2016. The Veteran through counsel wrote in part, “I believe I am entitled to the following: (1) Service connection for depression.” The Veteran was afforded a July 2016 VA psychiatric examination. The VA examiner rendered a medical opinion: As noted above, the Vet has already participated in a previous C&P initial mental health DBQ previously in August, 2010. Since that time, the Vet and his daughter report he has experienced a stroke and there appeared to be clear residual cognitive problems in evidence during the evaluation. At present, the DSM-5 diagnosis that appears most appropriate for the Veteran at present is Unspecified Neurocognitive Disorder. The exact date of onset of the Vet’s Unspecified Neurocognitive Disorder is difficult to state definitively though it does appear to correspond to his stroke that was reported to have occurred approximately 5 years ago. The clinical psychologist further elaborated: The Vet was not a reliable historian and displayed clear cognitive deficits during the evaluation. His daughter noted that approximately 5 years ago he experienced a stroke, though he did not present to the VA for treatment and there are no records regarding this as daughter noted they presented to a local ER and after being released he did not return for F/U treatment. In reviewing Vet’s VA records, there is no mention of stroke though he has been followed by neurology since Aug, 2011 for seizure disorder, though he has been noted to be seizure free since 2011 at neurology encounters, and while he had been stabilized on anti-seizure medications it is noted in recent treatment encounter notes that he decided to stop taking these on his own. At his last PCP treatment encounter on March 10, 2015, he was noted to have multiple medical problems but has not followed up here since that time (though no history of stroke noted at this or any previous VA treatment encounters here). The VA examiner concluded: While his Unspecified Neurocognitive Disorder is at least as likely as not attributable to the stroke reported by daughter, it is also possible that his comorbid medical conditions including untreated seizure disorder, Hepatitis C and untreated sleep apnea may also be contributing factors in his current cognitive problems, though definitive statements regarding etiology are deferred to medical providers. Next, the Veteran and his attorney submitted a January 2017 Brief. At the outset, they reasserted their theory of entitlement this time as one of direct service connection for depressive disorder. This is reflected statement of “Issues” section and “Argument” section on the first and second pages. Included in the January 2017 Brief is a January 2017 updated private medical opinion associated with other files from Dr. H.-G., though not specifically signed by Dr. H.-G. Dr. H.-G. references various life changes for the Veteran since the August 2010 VA examination. It shows, “His debilitating depression has caused a remarkable decline in his quality of life.” Dr. H.-G. found, “These service connected medical disorders continue to manifest as a depression, moreover, this expert opines the lumbosacral strain, prepyloric ulcer, bilateral hearing loss and hemorrhoids have caused the depression.” The Disability Benefits Questionnaire (DBQ) cited is a copy from November 2013. Dr. H.-G. concluded: Therefore, it should be noted that the disease pattern cannot be attributed to one particular medical condition rather, all conditions may indeed contribute to the overall decompensation and disability of this Veteran. It is the belief of this examiner based on interview and the C-File that Mr. [Veteran’s] lumbosacral strain, prepyloric ulcer, bilateral hearing loss and hemorrhoids are more likely than not causing his depressive disorder and preventing him from maintaining substantially gainful employment. VA and private treatment records are substantially the same. They show a history of heavy drinking and marijuana abuse. Here, there are inconsistencies in the medical opinions and additional development is necessary in light of the Veteran’s attorney’s contention regarding his theories of entitlement. The July 2016 VA examiner found Unspecified Neurocognitive Disorder and related the disability to a reported stroke. Second, the January 2017 private medical opinion described a worsening, and shows a diagnosis of depression under a theory of secondary service connection. There is no evidence of a contemporaneous examination of the Veteran, despite a reference to an interview. The January 2017 medical opinion does not consider the stroke reported by the Veteran. The January 2017 private medical opinion is listed in terms of, “[A]ll conditions may indeed contribute to the overall decompensation and disability of this Veteran.” The opinion expressed is not determinative. It also does not address a history of heavy drinking and marijuana abuse. It is not directly signed by the examiner. In contrast to this with this, the Veteran through counsel most recently argued in the January 2017 Brief that service connection on a direct basis is warranted. There is no medical opinion of record addressing depression on a direct basis. There is some evidence of disability accompanied by varying diagnoses and secondary etiology opinions. For example, the July 2016 VA examiner found a possible relationship to several disabilities, but did not render a diagnostic impression of depression, only Unspecified Neurocognitive Disorder. Consequently, a remand is necessary in light of the Veteran’s attorney’s most recent explanation of his theory of entitlement, to resolve the inconsistencies in the diagnoses, and to fully develop the Veteran’s claim. The Board also notes that the most recent January 2017 VA examination references a “remarkable decline” in quality of life, possibly demonstrative of a worsening in severity. On remand, the theory of secondary service connection should also be fully developed in accordance with the governing statute. See 38 C.F.R. § 3.310. As such the Board finds that a supplemental VA examination with medical opinion is warranted. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, the entire claims file should be made available to the VA examiner for review. Lastly, any outstanding VA treatment records since 2016 should be included in the claims file. See Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. Entitlement to a TDIU is remanded. The Board incorporates its discussion from the sections above by reference. Based on the fact that the acquired psychiatric disorder claim is being remanded, and the medical opinions submitted by the Veteran discuss how his psychiatric symptoms affect his ability to maintain employment, the TDIU claim is inextricably intertwined with the claim for service connection for an acquired psychiatric disorder. Hunt v. Nicholson, 20 Vet. App. 519, 525 (2005); Harris v. Derwinski, 1 Vet. App. 180, 183-4 (1991), overruled on other grounds; see Tyrues v. Shinseki, 23 Vet. App. 166 (2009). Consequently, a remand is warranted. The matters are REMANDED for the following action: 1. Obtain updated copies of the Veteran’s VA treatment records since 2016, and associate them with the Veteran’s claims folder. 2. Please schedule the Veteran for a VA examination to determine the nature and etiology of any acquired psychiatric disorder, claimed as depression, other than (exclusive of) PTSD and anxiety. The claims file should be made available to the VA examiner. For each diagnosed disability (exclusive of) PTSD and anxiety, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. Second, the VA examiner should also opine whether any diagnosed acquired psychiatric disorder (exclusive of) PTSD and anxiety is proximately due to, the result of, or aggravated by the Veteran’s service-connected disabilities, including lumbosacral strain, prepyloric ulcer, bilateral hearing loss disability, and hemorrhoids. Third, the examiner should also comment on the Veteran’s ability to function in an occupational environment, and describe the functional impairment caused solely by service-connected disability or disabilities, including any acquired psychiatric disorder. Attention is directed to Veteran and his daughter’s lay reports at the July 2016 VA examination of suffering a stroke. Attention is also directed to the VA treatment records showing a history of heavy drinking and marijuana abuse. The examiner should provide a rationale for all opinions expressed. 3. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his attorney an appropriate supplemental statement of the case (SSOC). Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel