Citation Nr: 18156922 Decision Date: 12/11/18 Archive Date: 12/11/18 DOCKET NO. 17-65 860 DATE: December 11, 2018 ORDER New and material evidence has been received to reopen a claim of entitlement to service connection for a left knee disability. New and material evidence has been received to reopen service connection for a left ankle disability. New and material evidence has not been submitted to reopen the claim of entitlement to service connection for tinea versicolor of the face and head. Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a right elbow disability is denied. Entitlement to service connection for residuals of a vasectomy is denied. Entitlement to a rating in excess of 30 percent for hypertensive heart disease is denied. Entitlement to a compensable rating for hypertension is denied. Entitlement to a rating in excess of 20 percent for diabetes mellitus type 2 is denied. Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to an effective date earlier than September 29, 2015, for the award of service connection for PTSD is denied. REMANDED Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a left wrist disability is remanded. Entitlement to a rating in excess of 10 percent for chronic lumbosacral strain is remanded. Entitlement to a compensable rating for right knee strain is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. A September 2005 rating decision denied service connection for a left knee disability, a left ankle disability, and tinea versicolor of the face and head. The Veteran did not appeal that decision, and new and material evidence was not received within one year of notice of its issuance. 2. Evidence received more than one year since the September 2005 rating decision denying service connection for a left knee and left ankle disability, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim of service connection for a left knee and left ankle disabilities, and raises a reasonable possibility of substantiating the claims. 3. The evidence received since the September 2005 rating decision is cumulative and redundant of evidence previously considered and does not raise a reasonable possibility of substantiating the claim of service connection for tinea versicolor of the face and head. 4. The Veteran’s right shoulder disability did not have its onset in service and is not otherwise related to service. 5. The Veteran’s right elbow disability did not have its onset in service and is not otherwise related to service. 6. The Veteran has not had residuals of a vasectomy just prior to or during the pendency of the claim. 7. The Veteran’s hypertensive heart disease has not been manifested by more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 metabolic equivalents (METs) but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 8. The Veteran’s hypertension has not been manifested by a history of diastolic pressure of 100 or more and requires continuous medication for control, diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more. 9. At no time during the appeal period has the Veteran’s diabetes mellitus type 2 required regulation of activities. 10. At no time during the appeal period has the Veteran’s PTSD resulted in total social and occupational impairment. 11. The record does not reflect that the Veteran filed a formal or informal claim or an intent to file a claim for service connection for an acquired psychiatric disorder, to include PTSD, prior to September 29, 2015. CONCLUSIONS OF LAW 1. The September 2005 rating decision denying the claim for service connection for a left knee disability, a left ankle disability, and tinea versicolor of the face and head is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence has been received to reopen the claim of service connection for a left knee disability. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. New and material evidence has been received to reopen the claim of service connection for a left ankle disability. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. New and material evidence has not been received to reopen the claim of service connection for tinea versicolor of the face and head. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The criteria for service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for service connection for a right elbow disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for service connection for residuals of a vasectomy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for a rating in excess of 30 percent hypertensive heart disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.104, Diagnostic Code 7007. 9. The criteria for a compensable rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.104, Diagnostic Code 7101. 10. The criteria for a rating in excess of 20 percent for diabetes mellitus type 2 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.119, Diagnostic Code 7913. 11. The criteria for an initial rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411. 12. The criteria for an effective date earlier than September 29, 2015, for the award of service connection for PTSD are not met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.155 (to include as in effect prior to March 24, 2015), 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1976 to May 2005. These matters come before the Board of Veterans’ Appeals (Board) on appeal from May and June 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In his April 2017 VA Form 21-0958 (Notice of Disagreement (NOD)), the Veteran appealed the effective date assigned for service connection for diabetes, right knee strain, chronic lumbosacral strain, and hypertension. In a March 2018 letter, the RO issued a letter to the Veteran informing that the April 2017 NOD as to those issues was untimely and was not accepted (as such effective dates were assigned in September 2005 and December 2008 rating decisions). He has not appealed that determination. Hence, these matters are not on appeal and are not before the Board. The Board notes that the Veteran’s April 2017 NOD also included the matter of entitlement to an earlier effective date for service connection for hypertensive heart disease. Such has not been addressed by the RO (including the propriety of such NOD), and is referred to the RO for further development. In August 2018, the Veteran reasonably raised a claim for TDIU, pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). Such is not a separate claim, but a part of the claims on appeal. Finally, in August 2018, the Veteran submitted evidence relevant to these claims. However, the Veteran expressly waived initial RO consideration of this newly submitted evidence, and even without such an express waiver, his waiver would have been presumed given the date that the Veteran perfected his appeal of these claims (March 2018). See 38 U.S.C. § 7105(e). New and Material Evidence Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105. However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 C.F.R. § 5108. “New” evidence means existing evidence not previously submitted to agency decisionmakers. “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). In determining whether evidence is “new and material,” the credibility of the new evidence must be presumed. Justus v. Principi, 3 Vet. App. 510 (1992). The provisions of 38 U.S.C. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead one should ask whether the evidence could reasonably substantiate the claim to be reopened, either by triggering VA’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. 1. New and material evidence has been submitted to reopen the claim of entitlement to service connection for a left knee disability. 2. New and material evidence has been submitted to reopen the claim of entitlement to service connection for a left ankle disability. Historically, an unappealed September 2005 rating decision denied the Veteran’s claim of service connection for a left knee and ankle disabilities, based on findings that no permanent or chronic left knee disability was found. No additional evidence pertinent to this issue was associated with the claims file within the one-year appeal period. See 38 C.F.R. § 3.156(b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). Accordingly, the September 2005 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.202, 20.1103. Since the September 2005 rating decision, the Veteran submitted additional evidence, including VA treatment records showing diagnosis of left knee patellar tendonitis, and a March 2016 VA examination report notes the Veteran’s report of left ankle functional loss due to pain, stiffness and weakness. Saunders v. Wilkie, 886 F.3d 1356 (2018) ((holding that pain resulting in functional impairment constitutes a disability as contemplated in 38 U.S.C. § 1110, even in the absence of a presently-diagnosed condition). This evidence is new, in that it was not previously of record at the time of the September 2005 rating decision. See, e.g., April 2016 VA treatment record. Additionally, the newly submitted evidence is not cumulative or redundant of evidence already of record. Given the standard set forth in Shade, outlined above, the Board finds that the additional evidence is new and material within the meaning of 38 C.F.R. § 3.156, warranting reopening of the claim of service connection for a left knee disability. 3. New and material evidence has not been submitted to reopen the claim of entitlement to service connection for tinea versicolor of the face and head. Here, the September 2005 rating decision denied service connection for a left ankle disability and for tinea versicolor of the face and head. The Veteran did not appeal the determination, and new and material evidence was not received within one year of notice of its issuance. Therefore, the decision became final. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104, 3.156(b), 20.1103; cf. Bond, supra. The basis of the prior final denial of the claims was that the Veteran had no post-service diagnosis. The evidence considered at the time of the September 2005 rating decision included the Veteran’s service treatment records and a June 2005 VA examination report that found no diagnosis of the left ankle, including on x-rays of the ankle, or diagnosis of a skin disorder. Evidence added to the record since the September 2005 rating decision includes VA treatment and Social Security Administration (SSA) records continuing to show no diagnosis of a left ankle disability or skin disorder, as well as a March 2016 VA ankle conditions examination that found no left ankle disability because there was no pathology to render a diagnosis, including no noted functional impairment. See Villalobos v. Principi, 3 Vet. App. 450 (1992) (evidence that is unfavorable to a claimant is not new and material). This evidence is cumulative of evidence already of record at the time of the September 2005 rating decision, and does not include evidence of a left ankle disability or a skin disorder. Accordingly, as the evidence received since the final denial of the claim for service connection for a left ankle disability or a skin disorder is not new and material, the claim is not reopened. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table decision). 4. Entitlement to service connection for a right shoulder disability is denied. The Veteran asserts that his right shoulder disability is directly related to service, to include as a result of the cumulative impact of his duties (infantry special forces, parachutist jump master/instructor, air assault) and a documented 1992 injury therein, and that he has had recurrent right shoulder symptomatology since. See September 2015 Statement in Support of Claim; March 2016 VA shoulder conditions examination. The Veteran has a current diagnosis of bilateral shoulder strain. Id. Additionally, his service treatment records reflect that in May 1992 he received treatment for a right shoulder strain. It was noted he was playing basketball and injured the shoulder, and had also dislocated the shoulder before about two years earlier. Physical examination revealed no crepitus, no swelling, x-rays appeared within normal limits, and there was no gross bone deformity. Thus, the first two elements of service connection have been met, and the critical aspect of the case centers on element three, nexus to service. Regarding nexus, there is only one competent opinion of record, and it is against the claim. Specifically, the March 2016 VA examiner opined that the right shoulder disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner emphasized that the Veteran had full range of motion of the shoulder with no functional loss, and no deformities or swelling or tenderness to palpation of the glenohumeral joint, with normal x-rays. The examiner noted the Veteran’s treatment during service as well as his report of dislocating his shoulder approximately two years prior to the May 1992 treatment, but stated that as there was no information as to the type or severity of that dislocation, he was unable to conclude that the right shoulder strain was caused by service, to include as a result of performing numerous parachute jumps therein. This opinion, which was based on a review of the relevant evidence of record and with supporting rationale, is highly probative. Notably, there is no competent and credible evidence in support of the Veteran’s claim. To the extent the Veteran relates his right shoulder strain to service, he is not competent to do so, as he does not have the requisite medical expertise to opine as to the etiology of such a disorder. Even if the Board found the Veteran competent to relate his shoulder strain to service, his account of recurrent right shoulder symptoms since the injury during service is not credible, as it conflicts with more contemporaneous evidence. Specifically, he denied having/having had painful or “trick” shoulder; bone, joint or other deformity; or painful or swollen joints on March 1994 and September 2002 reports of medical history, and on March 1994 and May 1997 examination the upper extremities were found to be normal on clinical evaluation. The Board also notes that in May 2005, prior to his separation from service, the Veteran submitted a claim for compensation for multiple disabilities, but he did not include a claim for the right shoulder, and VA treatment records for at least the first three years after service include no complaint or symptomatology involving the right shoulder. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to service connection for a right elbow disability is denied. The Veteran asserts that his right elbow disability is directly related to service, to include as a result of the cumulative impact of his duties (infantry special forces, parachutist jump master/instructor, air assault) and a documented 1987 injury therein, and that he has had recurrent right elbow symptomatology since. See September 2015 Statement in Support of Claim; March 2016 VA elbow and forearm conditions examination. The Veteran has a current diagnosis of right elbow calcification triceps tendon. Id. Additionally, his service treatment records reflect that in November 1987, he received treatment for right elbow pain times three days; the assessment was a strained right elbow. Thus, the first two elements of service connection have been met, and the critical aspect of the case centers on element three, nexus to service. Regarding nexus, there is only one competent opinion of record, and it is against the claim. Specifically, the March 2016 VA examiner opined that she was unable to provide a definitive opinion on whether the parachute jumps caused the right elbow calcification of the triceps tendon based on the incident in the Veteran’s medical record from over 25 years ago without resorting to mere speculation. She noted review of the relevant records, including of the 1987 strain, but indicated that she could not offer an etiological opinion in relation to an isolated incident over 25 years prior. This opinion, which was based on a review of the relevant evidence of record and with supporting rationale, is highly probative, as the examiner considered all procurable and assembled data and offered a basis for conclusion as to the inability to opine without speculation. Notably, there is no competent opinion in support of the Veteran’s claim. To the extent the Veteran relates his right elbow calcification triceps tendon to service, he is not competent to do so, as he does not have the requisite medical expertise to opine as to the etiology of such a disorder. Moreover, the Board finds the Veteran’s account of recurrent right elbow symptoms since the injury during service not credible, as he specifically denied having/having had painful or “trick” elbow; bone, joint or other deformity; or painful or swollen joints on March 1994 and September 2002 reports of medical history, and on March 1994 and May 1997 examination the upper extremities were found to be normal on clinical evaluation. The Board also notes that in May 2005, prior to his separation from service, the Veteran submitted a claim for compensation for multiple disabilities, but the Veteran did not include a claim for the right elbow, and VA treatment records for at least the first three years after service include no complaint or symptomatology involving the right elbow. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to service connection for residuals of a vasectomy is denied. The question for the Board regarding the matter of service connection for residuals of a vasectomy is whether the Veteran has the disability in question. 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). Based on the evidence of record, the Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for residuals of a vasectomy, under any theory of entitlement, as the Veteran has not identified and the evidence does not show diagnosis of such disability or associated functional impairment. In this case, the Board must deny the claim for service connection for residuals of a vasectomy due to the absence of proof of current disability. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The percentage ratings in VA’s Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, “staged” ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). The appeal period before the Board for the increased rating claims is from the date of his claim, or September 29, 2015, plus the one-year lookback period. 7. Entitlement to a rating in excess of 30 percent for hypertensive heart disease is denied. The Veteran’s hypertensive heart disease (previously characterized as left ventricular hypertrophy) is evaluated under Diagnostic Code 7007. 38 C.F.R. § 4.104. Under Diagnostic Code 7007, a 30 percent rating is warranted for a workload of greater than 5 metabolic equivalent (METs) but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 38 C.F.R. § 4.104. A 60 percent rating is warranted if there is evidence of more than one episode of acute congestive heart failure in the past year; a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. A total (100 percent) rating is warranted based upon findings of chronic congestive heart failure, or a workload of 3 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. The particular unit of heart workload referenced above, one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory finding of METs by physical testing cannot be achieved for medical reasons, an estimate by a clinical examiner of the level of activity (expressed in METs and supported by examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). After a review of the evidence of record, the Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for the Veteran’s hypertensive heart disease. At no time during the appeal period has the Veteran’s hypertensive heart disease been manifested by acute congestive heart failure, a workload of greater than 3 METs but not greater than 5 METs, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. April 2016 echocardiogram revealed normal left ventricular ejection fraction of 55 to 65 percent, and mild asymmetric left ventricular septal myocardial hypertrophy. May 2016 VA heart conditions examination noted no evidence or history of myocardial infarction or congestive heart failure. In addition, the Veteran denied experiencing any symptoms attributable to a cardiac condition with any level of physical activity. As there is no evidence consistent with, or approximating, the criteria for a rating in excess of 30 percent, the Board finds that the criteria for a rating in excess of 30 percent for hypertensive heart disease is not warranted. Finally, the Board notes that when a condition is specifically listed in the Schedule, as is hypertensive heart disease, it may not be rated by analogy to another diagnostic code. Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). 8. Entitlement to a compensable rating for hypertension is denied. Hypertension is evaluated under Diagnostic Code 7101. 38 C.F.R. § 4.104. Under Diagnostic Code 7101, a 10 percent rating is warranted for hypertensive vascular disease with diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more, or a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. Id. A 20 percent rating is warranted for hypertensive vascular disease with diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. Id. Higher ratings are available for diastolic pressures predominantly 120 or more. Id. Hypertension may not be rated by analogy to another diagnostic code. Copeland, supra. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against a compensable rating for the Veteran’s hypertension. At no time during the appeal period has recorded systolic pressure been greater than 160, diastolic pressure been greater than 100, or is there is evidence of diastolic pressure predominantly 100 or more who requires continuous medication for control. See, e.g., VA treatment records showing blood pressure readings of 133/81, 142/85, 129/85, 123/87, 132/88, 129/78; see also March 2016 hypertension examination report (finding blood pressure readings of 130/86, 132/84, 130/84). The Board acknowledges the Veteran’s hypertension requires continuous medication for control. However, given there is no evidence consistent with, or approximating, the criteria for an increased 10 percent rating during the appeal period, the Board finds that the criteria for an increased 10 percent rating for hypertension is not warranted. 9. Entitlement to a rating in excess of 20 percent for diabetes mellitus type 2 is denied. Diabetes mellitus is rated under Diagnostic Code 7913, which provides for a 20 percent rating when insulin and a restricted diet, or, an oral hypoglycemic agent and a restricted diet are required. A 40 percent rating is warranted when insulin, restricted diet, and regulation of activities are required. A 60 percent rating is warranted when insulin, a restricted diet, and regulation of activities are required, along with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating requires more than one daily injection of insulin, a restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately rated. 38 C.F.R. § 4.119. Note 1 following Diagnostic Code 7913 provides that compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable evaluations are considered part of the diabetic process under Diagnostic Code 7913. Diabetes mellitus may not be rated by analogy to another diagnostic code. Copeland, supra. What distinguishes the schedular criteria for the current, 20 percent, rating for diabetes from those for the next higher, 40 percent, rating is that in addition to requiring diet and insulin for control, the diabetes must also require regulation of activities (defined as the “avoidance of strenuous occupational and recreational activities”). 38 C.F.R. § 4.119, Code 7913 (defining term within criteria for a 100 percent rating). The Board notes that the criteria for the progressively increasing ratings for diabetes are stated in the conjunctive rather than the disjunctive, i.e., each level of increase in the rating requires additional criteria which must be met to warrant the increase in the rating. See Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). After a review of the evidence of record, the Board finds that the preponderance of the evidence is against a finding a rating in excess of 20 percent is warranted at any period during the appeal period. There is no evidence that at any time during the appeal period the Veteran’s diabetes has required regulation (avoidance) of activities. While the March 2016 VA diabetes mellitus examiner indicated the Veteran’s diabetes requires regulation of activities, the Board infers the examiner noted this in error, as the associated justification was that he walks daily as part of the medical management of his diabetes and such activity is consistent with encouraging activity as treatment, and not avoidance of activity as treatment. Jackson v. Virginia, 443 U.S. 307, 319 (1979) (stating it is “the responsibility of the trier of fact fairly to... draw reasonable inferences from basic facts to ultimate facts”); Bastien v. Shinseki, 599 F.3d 1301, 1306 (Fed. Cir. 2010) (“The evaluation and weighing of evidence and the drawing of appropriate inferences from it are factual determinations committed to the discretion of the fact finder.”). In support of this finding, VA treatment records show no evidence, or suggestion, the Veteran was instructed to regulate his activities in order to treat his diabetes. See April 2016 VA treatment record (noting the Veteran’s diabetes control slipped when he was not able to exercise in the cold weather, but has since resumed activity); November 2017 VA treatment record (noting the Veteran exercises 6 to 7 days per week). Accordingly, the evidence does not show that at any time during the appeal period manifestations of the Veteran’s diabetes mellitus satisfied, or approximated, the criteria for the next higher, 40 percent, rating. See 38 C.F.R. § 4.7. Consequently, such rating, or any rating above 40 percent, is not warranted. Furthermore, the record does not reflect any additional separately compensable complications of diabetes. Notably, the Veteran has separately been awarded service connection for erectile dysfunction as associated with his diabetes. The March 2016 VA diabetes mellitus examination specifically indicated the Veteran did not suffer from peripheral neuropathy, nephropathy or renal dysfunction, or retinopathy secondary to his diabetes. There is no evidence of, or suggestion, that the Veteran suffers from any other complication as a result of his service-connected diabetes mellitus. 10. Entitlement to an initial rating in excess of 70 percent for PTSD is denied. The Veteran’s PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 (the General Rating Formula for Mental Disorders (General Formula)), which provides for a 70 percent rating when the evidence shows 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 worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when the evidence shows 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. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When determining the appropriate disability evaluation to assign, however, the Board’s “primary consideration” is the Veteran’s symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The appeal period before the Board is from September 29, 2015. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against a finding an initial rating in excess of 70 percent is warranted at any period during the appeal. The evidence of record does not show, or approximate, total social and occupational impairment. Gross impairment in thought processes or communication has not been shown on any mental status examination. See, e.g., April 2016 VA examination (finding the Veteran’s insight and judgment were “good”); June 2018 examination. While there is evidence of memory loss, including as stated by the Veteran’s daughters (e.g., forgetting where one daughter went to law school), there is no evidence of such severe memory loss as contemplated in a total rating (e.g., memory loss for names of close relatives, own occupation, or own name). See April 2016 VA examination; June 2018 examination. There is also no evidence of disorientation to time or place, delusions or hallucinations, grossly inappropriate behavior, or persistent danger of hurting self or others. See June 2018 examination. In this regard, the Board acknowledges intermittent reports and complaints of suicidal ideation. See April 2016 VA PTSD examination (noting suicidal ideation); cf. January 2017 Dr. A.K. SSA report; January 2018 VA treatment record. Notably, the Court has held that suicidal ideation, alone, may warrant a 70 percent rating. See Bankhead v. Shulkin, 29 Vet. App. 10, 19-20 (2017). Inasmuch as the Veteran is already rated 70 percent, and the evidence supports a finding the suicidal ideation is intermittent in nature, the Board finds the preponderance of the evidence is against a finding the Veteran’s suicidal ideation is consistent with or approximates persistent danger of hurting self as provided for an increased 100 percent rating. While the June 2018 examiner noted an intermittent inability to perform activities of daily living, which is supported by the lay statements of the Veteran’s daughters, K.C. and G.C., no other symptoms of similar severity, frequency or duration to those listed for assignment for a 100 percent rating are demonstrated, and the Veteran’s overall impairment does not result in total social impairment. In this regard, the Veteran maintains close relationships with his three daughters, and has a current girlfriend. See, e.g., April 2016 VA PTSD examination; June 2018 examination (noting current relationship times 4 years). Accordingly, as total social impairment has not been shown, and a 100 percent rating is not warranted for the Veteran’s PTSD at any period during the appeal period. 11. Entitlement to an effective date earlier than September 29, 2015, for the award of service connection for PTSD is denied. The provisions governing the assignment of the effective date of an increased rating are set forth in 38 U.S.C. § 5110(a) and (b)(2), and 38 C.F.R. § 3.400(o). Generally, the effective date of an award of increased compensation “shall not be earlier than the date of receipt of the application thereof.” 38 U.S.C. § 5110(a). This statutory provision is implemented by regulation that provides that the effective date for an award of increased compensation will be the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). On March 24, 2015, VA amended its regulations to require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57,660 (Sept. 25, 2014). Prior to March 24, 2015, VA allowed for the filing of informal claims without any particular format or requirements aside from (1) an intent to apply for benefits; (2) an identification of the benefits sought; and (3) a communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); 38 C.F.R. §§ 3.1 (p), 3.155 (2014). The revised regulation allows a claimant to submit an intent to file a claim, and VA may recognize the receipt date of the intent to file a claim as the date of claim so long as VA receives the successfully completed claim form within a year. 38 C.F.R. § 3.155(b). There are three ways in which a claimant may submit an intent to file a claim: (i) saved electronic application – when an application otherwise meeting the requirements of paragraph (b) is electronically initiated and saved in a claims-submission tool with a VA web-based electronic claims application system, (ii) written intent, signed and dated on the intent to file a claim form prescribed by the Secretary, and (iii) oral intent communicated to designated VA personnel, recorded in writing, and documented in the claimant's records. Id. In this case, the Veteran submitted a VA Form 21-4138 that was received on September 29, 2015, detailing some of the activities and duties of his military service. Thereafter, on October 5, 2015, the Veteran submitted a VA Form 21-526b (Veteran’s Supplemental Claim for Compensation) for a claim for “stress.” In a May 2016 rating decision, the RO awarded service connection for PTSD, effective September 29, 2015. The Veteran did not submit any other intent to file a claim between March 24, 2015 and September 29, 2015, or request for an application which would allow for an earlier effective date for service connection. Nor has the Veteran identified, and the record does not otherwise reflect, an informal or formal claim for a psychiatric disorder prior to March 24, 2015. Consequently, there is no basis for awarding an effective date prior to September 29, 2015, for service connection for PTSD. REASONS FOR REMAND 12. Entitlement to service connection for a left knee disability is remanded. The Veteran was afforded a VA examination regarding his claim for service connection for a left knee disability in March 2016. The examiner found there was no left knee diagnosis because there was no pathology to render a diagnosis. However, as noted above, the record contains a diagnosis of left knee patellar tendonitis. Accordingly, this matter must be remanded for an addendum opinion. 13. Entitlement to service connection for a left ankle disability is remanded. 14. Entitlement to service connection for a left wrist disability is remanded. The Veteran reports of left ankle functional loss due to pain, stiffness and weakness and left wrist functional loss due to pain and stiffness, satisfying the requirement of a current disability. See Saunders, supra. Accordingly, the March 2016 VA examiner’s nexus opinions are inadequate, as they are based on lack of a current diagnosis, requiring an addendum opinion on remand. 15. Entitlement to a rating in excess of 10 percent for chronic lumbosacral strain is remanded. 16. Entitlement to a compensable rating for right knee strain is remanded. Regarding the lumbosacral spine and right knee, the Veteran was last afforded VA examinations in March 2016, which were not wholly adequate pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Thus, a new examination is necessary on remand. 17. Entitlement to TDIU is remanded. A completed Application for Increased Compensation Based on Unemployability, VA Form 21-8940, is needed on remand. See January 2017 record from Dr. A.C. (noting that the Veteran has been a property manager since 2014). Outstanding treatment records should also be secured. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any outstanding relevant private treatment records. 3. Provide the Veteran an Application for Increased Compensation Based on Unemployability, VA Form 21-8940, and appropriate notice for a claim for entitlement to a TDIU rating. 4. Obtain an addendum opinion regarding the etiology of the Veteran’s left knee, left ankle and left wrist disabilities. The claims file should be provided to and reviewed by the examiner. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. Based on review of the record, the examiner should provide an opinion that responds to the following: (a) For diagnosed left wrist and left ankle disabilities, please opine as to whether it is at least as likely as not (50 percent or greater probability) that such disabilities had their onset in service or are otherwise related to service, to include as a result of the cumulative impact of repetitive trauma associated with his duties (infantry special forces, parachutist jump master/instructor, air assault). Please concede the presence of a current disability, and discuss the November 1976 STR noting pain in the left wrist and the February 1979, December 1980 and January 1981 STRs noting left ankle pain and sprain. Please note the Veteran has been granted service connection for a right knee disability as directly related to trauma from parachute jumping. (b) For diagnosed left knee patellar tendonitis (see September 2015 VA treatment record), please opine as to whether it is at least as likely as not (50 percent or greater probability) that such disability: (1) had its onset in service or is otherwise related to service, to include as a result of the cumulative impact of repetitive trauma associated with his duties (infantry special forces, parachutist jump master/instructor, air assault). (2) is proximately due to his service-connected right knee strain; or (3) has been aggravated (worsened beyond natural progression) by his service-connected right knee strain. The examiner should acknowledge and discuss that the Veteran’s service-connected right knee strain was granted as directly related to trauma from parachute jumping. A detailed rationale for any opinion expressed should be provided. If the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner explain why an opinion cannot be provided. 5. Then schedule the Veteran for a VA examination to determine the current nature and severity of his lumbosacral spine and right knee disabilities. The claims file, to include a copy of this remand, must be made available to and reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. The examiner is asked to address the following: (a) Full range of motion testing must be performed. The joints involved should be tested in (1) active motion, (2) passive motion, (3) in weight-bearing, (4) in nonweight-bearing. Please specify range of motion measurements in all areas outlined above. 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. (b) Considering the Veteran’s reported history, please also provide an opinion describing functional impairment of the Veteran’s lumbosacral spine and right knee disabilities due to flare-ups, accounting for pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report such impairment in terms of additional degrees of limitation of motion. If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician’s Guide to estimate, “per [the] veteran,” what extent, if any, flare-ups affect functional impairment. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. S. BUSH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Marley, Counsel