Citation Nr: 18157873 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 15-28 243 DATE: December 13, 2018 ORDER New and material evidence not having been received, the appeal to reopen service connection for a low back condition is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for hepatitis C is granted. An effective date earlier than July 9, 2012, for the award of service connection for left eye conjunctivitis/ptosis, claimed as a left eye condition, is not warranted, and the appeal is denied. Entitlement to an initial rating in excess of 10 percent for left eye conjunctivitis/ptosis is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include depressive disorder, is remanded. Entitlement to service connection for headaches, to include as secondary to an acquired psychiatric disorder, is remanded. FINDINGS OF FACT 1. Service connection for a low back condition and left eye condition were denied in an October 1997 rating decision, and the Veteran did not appeal the decision. 2. Evidence received since the October 1997 rating decision is new but not material and does not support the application to reopen service connection for a low back condition. 3. The preponderance of the evidence is against finding that the Veteran has a current left knee diagnosis. 4. The preponderance of the evidence is against finding that the hypertension is due to a disease or injury in service. 5. The Veteran’s current hepatitis C is etiologically related to service. 6. The Veteran’s request to reopen the claim for service connection for a left eye condition was received at VA on July 9, 2012. No formal or informal claim for a left eye disability was received prior to October 2012 that was not adjudicated in the October 1997 rating decision. 7. For the entire period of appeal, the left eye conjunctivitis/ptosis has been rated as 10 percent disabling under Diagnostic Code 6018, which is the maximum rating for active conjunctivitis under this diagnostic code. The conjunctivitis/ptosis has not resulted in corrected visual acuity of 20/200 or remaining visual field of 15 degrees or less. CONCLUSIONS OF LAW 1. New and material evidence has not been received to reopen the claim for service connection for a low back condition. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 3.159, 20.1103. 2. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for service connection for a low back condition are not met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 4. The criteria for service connection for hepatitis C are met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 5. The criteria for the assignment of an effective date earlier than July 9, 2012, for the award of service connection for the left eye conjunctivitis/ptosis are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.155(a), 3.400. 6. The criteria for an initial rating in excess of 10 percent for left eye conjunctivitis/ptosis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.79, Diagnostic Code 6018. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from November 1976 to October 1980. New and Material Evidence Rating decisions from which an appeal is not perfected become final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. An appeal consists of a timely filed notice of disagreement in writing, and after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. To reopen a claim that has been denied by a final decision, new and material evidence must be received. 38 U.S.C. § 5108. New and material evidence means evidence not previously submitted to agency decisionmakers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is 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 which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216, 220 (1994); Justus v. Principi, 3 Vet. App. 510, 513 (1992). 1. New and material evidence to reopen a claim for service connection for a low back condition. The Veteran submitted a claim for service connection for a low back condition in July 1997, which was denied in an October 1997 rating decision because although there was a record of treatment in service for a low back condition, the evidence did not show permanent residual or chronic disability and the Veteran failed to report for a VA examination scheduled in October 1997. The rating decision noted that to substantiate a claim for service connection, there must be evidence of a current disability, evidence of incurrence or aggravation of a disease or injury in service, and evidence of a nexus (or link) between the in-service injury or disease and the current disability. The evidence of record at the time of the rating decision consisted of the Veteran’s service treatment records and the application for compensation benefits. The Veteran was notified of the rating decision in November 1997 and he did not perfect an appeal. As such, the decision is final. In July 2012, the Veteran requested to reopen the claim for service connection for a low back condition. The additional evidence received in support of the application to reopen consists of private treatment records dated between 2011 and 2013 and a VA back examination conducted in June 2013. The Board finds that the evidence submitted since the October 1997 rating decision is new, but it is not material because it does not relate to an unestablished fact necessary to substantiate the claims for service connection for a low back condition. Specifically, the evidence does not indicate that any current low back diagnosis is related to service. Rather, the June 2013 VA examiner opined that the current back condition was less likely than not incurred in or caused by the claimed in-service injury, and there is no medical opinion in the claims file that contradicts the conclusions of the VA examiner. To the extent to which the Veteran asserts the onset of the condition was in service or attempts to provide such a link, this is cumulative of his statements prior to the October 1997 rating decision. Reid v. Derwinski, 2 Vet. App. 312 (1992). See also Bostain v. West, 11 Vet. App. 124 (1998) (lay hearing testimony that is cumulative of previous contentions considered by decision maker at time of prior final disallowance of the claim is not new evidence). Thus, the Veteran’s lay statements on their own are not sufficient to serve as new and material evidence to reopen the claim. As such, the evidence submitted since the October 1997 rating decision does not relate to an unestablished fact necessary to substantiate the claim for service connection for a low back condition. Accordingly, new and material evidence has not been received to reopen service connection for a low back condition and the appeal is denied. Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310(a), (b). Service Treatment Records (STRs) In a September 1976 service enlistment examination, the Veteran’s lower extremities were noted to be clinically normal. His blood pressure was 102/58, and the Veteran denied having a history of high blood pressure, liver trouble, and venereal disease (VD). In August 1977, the Veteran reported injuring his knee during a team handball game. He reported having soreness in his knee. The treatment record does not specify which knee was injured. In August 1979, the Veteran was noted to have VD and given penicillin; approximately one week later he was seen for a follow-up on GC (gonorrhea). In June 1980, the Veteran was diagnosed with gonorrhea after reporting three days of symptoms. In July 1980, the Veteran was noted to have had a penicillin injection two weeks ago for GC. He indicated in a dental questionnaire the same month that he had been treated for hepatitis and VD. In October 1980, the Veteran declined to have a medical examination upon separation from service. A physician then reviewed his STRs and determined that a medical examination for separation was not required. 2. Service connection for a left knee disability. The Board finds that the Veteran does not have a current left knee diagnosis. A private treatment record dated in March 2011 indicates that the Veteran denied having any joint or muscle pain or swelling. An April 2011 private treatment record indicates that there were no arthralgias or myalgias present. November 2011 and May 2012 private treatment records are silent for mention of any knee problems and the Veteran was noted to have a normal gait. In sum, there is no credible persuasive evidence that the Veteran suffers from a left knee disability productive of chronic functional impairment. Saunders v. Wilkie, No. 2017-1466, 2018 U.S. App. LEXIS 8467 (Fed. Cir. Apr. 3, 2018). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). The Veteran has not submitted any medical evidence that shows he has a diagnosed left knee disability during the appellate period or a diagnosis close in time to the appeal period. The Board has considered the Veteran’s reports attributing a left knee disability to service, but the evidence of record does not demonstrate that the Veteran has the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation in a case involving complex medical facts. The Veteran is therefore not competent to provide an opinion on the etiology of any left knee disability. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In the absence of any persuasive and probative evidence that the Veteran has a left knee disability that is etiologically related to active service, service connection is not warranted and the claim must be denied. 3. Service connection for hypertension. The Board finds that service connection for hypertension is not warranted. A private treatment record dated in March 2011 indicates that the Veteran had a diagnosis of hypertension. Subsequent private treatment records dated between 2011 and 2013 indicate that he was taking hydrochlorothiazide daily. The Board finds that any current hypertension diagnosis did not begin during service and is not otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Although private treatment records clearly indicate a diagnosis of hypertension, the records are dated no earlier than 2011, which is more than 30 years after the Veteran’s separation from service. This lengthy period of time without diagnosis or treatment weighs against the finding that the hypertension has existed since service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Furthermore, STRs are silent for mention of diagnosis or treatment of hypertension, and there is no medical evidence (i.e., no nexus opinion) in favor of the claim. As such, there is no competent medical evidence to establish a nexus between the current hypertension and a documented event or disease in service. 4. Service connection for hepatitis C. The Board concludes that the Veteran has a current diagnosis of hepatitis C that began during active service. 38 U.S.C. §§ 1131; Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303(a). In a June 2013 VA examination, the Veteran was noted to have been diagnosed with hepatitis C in 1983. The examiner indicated that the Veteran reported a history of using drugs, including intravenous (IV) drug use and intranasal cocaine use, and high-risk sexual behaviors. The current signs or symptoms attributable to hepatitis C included daily fatigue, intermittent malaise, intermittent nausea, daily arthralgia, intermittent right upper quadrant pain, and hepatomegaly. The examiner opined that the hepatitis C was less likely than not incurred in or caused by service because due to the Veteran’s history of IV drug use and high risk sexual activity, it would be “very presumptuous” to assume that the hepatitis C was due to his active duty military service. In a January 2017 letter, a private physician, Dr. H.S., indicated that he had reviewed the Veteran’s STRs and interviewed the Veteran, and concluded that the Veteran contracted hepatitis C in military service, likely from high-risk sexual activity. Dr. H.S. noted that STRs showed the Veteran was diagnosed with gonorrhea and reported a positive history of hepatitis. He also noted that the Veteran admitted to high-risk sexual activity and intranasal cocaine use while in service, but “adamantly denies” the use of IV drugs, “not even once.” Dr. H.S. noted that medical literature supported that intranasal cocaine use alone was not a substantial risk factor for hepatitis. When there is an approximate balance of positive and negative evidence on any issue material to the determination of a matter the issue must be resolved in favor of the Veteran. 38 U.S.C. § 5107. Here, as discussed above, there is evidence that the Veteran was treated for gonorrhea and general VD while in service, and at least one STR indicates that the Veteran was also treated for hepatitis. He was diagnosed with hepatitis C only a few years after separation from service, and Dr. H.S. opined that the hepatitis C was more likely than not from high-risk sexual activity while in service. As such, there is enough evidence to find a nexus between the Veteran’s service and the claimed disability, and service connection for hepatitis C is granted. Earlier Effective Date & Increased Rating 5. Earlier effective date for the award of service connection for left eye conjunctivitis/ptosis. The Veteran contends without further elaboration that an effective date earlier than July 9, 2012, for the award of service connection for left eye conjunctivitis/ptosis. See the April 2014 statement, August 2015 VA Form 9. In general, the effective date of an award of disability compensation, in conjunction with a grant of entitlement to service connection, shall be the day following separation from active service or the date entitlement arose if the claim is received within one year of separation from service; otherwise, the effective date shall be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(b)(2)(i). The law grants a period of one year from the date of the notice of the result of the initial determination for initiating an appeal by filing a notice of disagreement; otherwise, that determination becomes final and is not subject to the revision on the same factual basis in the absence of clear and unmistakable error (CUE). 38 U.S.C. § 7105; 38 C.F.R. § 3.105(a). Here, service connection was denied in an October 1997 rating decision and the Veteran was notified of the decision the next month. He did not file a notice of disagreement. Accordingly, the October 1997 rating decision is final, and 1997 is no longer the appropriate point from which to determine the effective date of an award unless a claim for CUE is submitted. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). On July 9, 2012, the Veteran requested to reopen the claim for a left eye condition. Service connection was granted in a July 2013 rating decision, effective July 9, 2012. The Board finds that the earliest effective date for the award of service connection is July 9, 2012. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(q) and (r). The Board has reviewed the record to determine whether an informal claim of service connection for a left eye condition was filed prior July 9, 2012, that can be construed as an informal or formal claim for compensation benefits for a left eye disability and was not adjudicated in the October 1997 rating decision, but finds that there is no such document in the claims file. See 38 C.F.R. §§ 3.151, 3.155; Rudd v. Nicholson, 20 Vet. App. 296 (2006) (holding that a freestanding claim for effective date earlier than the date on which the claim was received, impermissibly attempts to vitiate the rule of finality). Accordingly, under the applicable regulations, July 9, 2012, is the earliest date for the award of service connection for the left eye conjunctivitis/ptosis absent an appeal of whether CUE was committed in a prior rating decision. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. Because the preponderance of the evidence is against the claim for an earlier effective date, the benefit of the doubt doctrine is not for application and the appeal is denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). 6. Increased rating for left eye conjunctivitis/ptosis. The Veteran’s left eye conjunctivitis/ptosis is rated under Diagnostic Code 6018, for chronic conjunctivitis. 38 C.F.R. § 4.79. Under the regulations that went into effect on December 10, 2008, chronic conjunctivitis warrants a 10 percent rating when it is active (with objective findings such as red, thick conjunctivae, mucous secretion, etc.). When the conjunctivitis is inactive is to be evaluated based on residuals, such as visual impairment and disfigurement. 38 C.F.R. § 4.79, Diagnostic Code 6018. With respect to field of vision impairment, 38 C.F.R. § 4.76a, Table III, the normal visual field extent at the 8 principal meridians totals 500 degrees. The normal for the 8 principal meridians are as follows: 85 degrees temporally; 85 degrees down temporally; 65 degrees down; 50 degrees down nasally; 60 degrees nasally; 55 degrees up nasally; 45 degrees up; and 55 degrees up temporally. The extent of visual field contraction in each eye is determined by recording the extent of the remaining visual fields in each of the eight 45-degree principal meridians. The degrees lost are then added together to determine the total number of degrees lost, which are subtracted from 500. The total remaining degrees of the visual field are then divided by eight to represent the average contraction for rating purposes. 38 C.F.R. § 4.76a. Under Diagnostic Code 6080, visual field defects are evaluated as follows: A 10 percent evaluation for concentric contraction of visual field with remaining field of 46 to 60 degrees bilaterally or unilaterally; with remaining field of 31 to 45 degrees unilaterally; with remaining field of 16 to 30 degrees unilaterally; loss of superior half of visual field bilaterally or unilaterally; loss of interior half of visual field unilaterally; loss of nasal half of visual field bilaterally or unilaterally; and loss of temporal half of visual field unilaterally. A 20 percent evaluation if assigned for concentric contraction of visual field with remaining field of 6 to 15 degrees unilaterally. A 30 percent evaluation is assigned for concentric contraction of visual field with remaining field of 31 to 45 degrees bilaterally; remaining field of 5 degrees unilaterally; loss of inferior half of visual filed bilaterally; loss of temporal half of visual field bilaterally; and homonymous hemianopsia visual filed defects. A 50 percent rating is assigned for concentric contraction of visual field with remaining field of 16 to 30 degrees bilaterally. A 70 percent rating is assigned for concentric contraction of visual field with remaining field of 6 to 15 degrees bilaterally. A 100 percent rating is assigned for concentric contraction of visual field with remaining field of 5 degrees bilaterally. Visual impairment is also rated based on impairment of visual acuity (excluding developmental errors of refraction). 38 C.F.R. § 4.79, Diagnostic Codes 6061-6066. 38 C.F.R. § 4.76(b) dictates that evaluation of visual acuity should be done on the basis of corrected distance vision with central fixation, unless the lens required to correct distance vision in the poorer eye differs by more than three diopters from the lens required to correct distance vision in the better eye. A 10 percent rating is warranted only when there is (1) 20/50 vision in one eye with 20/40 or 20/50 vision in the other eye; (2) 20/70 vision in one eye with 20/40 vision in the other eye; or (3) 20/100 vision in one eye with 20/40 vision in the other eye. A 20 percent rating is warranted when there is (1) 20/70 vision in one eye with 20/50 vision in the other eye; (2) 20/100 vision in one eye with 20/50 vision in the other eye; (3) 20/200 vision in one eye with 20/40 vision in the other eye; or (4) 15/200 vision in one eye with 20/40 vision in the other eye. A 30 percent rating is warranted (1) when vision in both eyes is correctable to 20/70; (2) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/70; (3) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/50; (4) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/50; (5) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/40; (6) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/40; and (7) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/40. A 40 percent rating is warranted (1) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/70; (2) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/50; (3) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/50; (4) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/50 or (5) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/40. A 50 percent disability rating is warranted (1) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/100; (2) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/70; (3) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/70; (4) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/70; or (5) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/50. A 60 percent disability rating is warranted (1) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/100; (2) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/100; (3) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/200; (4) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/100; (5) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/100; or (6) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/70 or 20/100. A 70 percent disability rating is warranted (1) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/200; (2) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/200; (3) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/200; (4) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/200; (5) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/200; or (6) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/200. An 80 percent disability rating is warranted (1) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 15/200; (2) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 15/200; (3) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 15/200; (4) when vision in one eye is no more than light perception and vision in the other eye is correctable to 15/200; or (5) when there is anatomical loss of one eye and vision in the other eye is correctable to 15/200. A 90 percent disability rating is warranted only (1) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 10/200; (2) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 10/200; (3) when vision in one eye is no more than light perception and vision in the other eye is correctable to 10/200; or (4) when there is anatomical loss of one eye and vision in the other eye is correctable to 10/200. A 100 percent disability rating is warranted only (1) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 5/200; (2) when vision in one eye is no more than light perception and vision in the other eye is correctable to 5/200; (3) when there is anatomical loss of one eye and vision in the other eye is correctable to 5/200; (4) when there is no more than light perception in both eyes; or (5) when there is anatomical loss of both eyes. To determine the rating for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service-connected, separately rate the visual acuity and visual field defect, expressed as a level of visual acuity, and combine them under the provisions of § 4.25. 38 C.F.R. § 4.77(c). The Board concludes that for the entire period of appeal, a rating in excess of 10 percent for the left eye conjunctivitis/ptosis is not warranted under Diagnostic Code 6018. A March 2013 private treatment record indicates that the Veteran reported that his left eye was itchy and occasionally painful. He stated that it felt like something was in his eye. He was not using any eye drops, which made the eye feel worse. Upon examination, the Veteran’s pupils were equal, round, and reactive, without any afferent pupillary defect. His uncorrected distance vision was 20/25-1 bilaterally, and confrontation fields were full to finger counting. The Veteran was diagnosed with bilateral pinguecula and keratitis sicca. He was advised to use Systane as needed for dryness and discomfort. The Veteran had a VA eye examination in June 2013. He was noted to have left eye discomfort and use of drops since the in-service eye trauma, as well as a diagnosis of Bell’s palsy in 2005 with persistent eyelid edema. On examination, the Veteran’s uncorrected and corrected bilateral near and distance vision was 20/40 or better. His pupils were equal in size, round, and reactive to light, without an afferent pupillary defect. He did not have anatomical loss, light perception only, extremely poor vision, or blindness of either eye. The Veteran also did not have corneal irregularity that resulted in severe irregular astigmatism, diplopia (double vision), a visual field defect, or any incapacitating episodes. His diagnoses included left eye ptosis, which did not cause a decrease in visual acuity or other visual impairment, but did cause gross distortion or asymmetry of the eyes; left eye nontrachomatous active conjunctivitis; and bilateral pinguecula, but much more pronounced in the left eye. As noted above, the maximum rating for chronic conjunctivitis (nontrachomatous) that is active is 10 percent. 38 C.F.R. § 4.79, Diagnostic Code 6018. As such, the Veteran has been in receipt of the maximum rating allowed for his bilateral conjunctival injection under this diagnostic code throughout the entire rating period. To warrant a higher 20 percent rating based on impaired central visual acuity, the evidence must show that vision in one eye is 20/40 and vision in the other eye is 20/200. 38 C.F.R. § 4.79, Diagnostic Code 6066. Alternatively, to warrant a higher rating based on visual field defect, the evidence must show contraction of the central visual field with a remaining field of six to 15 degrees. 38 C.F.R. § 4.79, Diagnostic Code 6080. Here, the Veteran has not been found to have an impairment in visual acuity worse than 20/40, impairment in visual field, nor was he been found to have any incapacitating episodes, or scarring to warrant a higher rating or any additional ratings under other diagnostic codes. The Board acknowledges that the VA examiner found that the ptosis caused assymetry of the eyes and that his diagnoses include bilateral pinguecula. Under Diagnostic Code 6019, ptosis is evaluated based on visual impairment, or in the absence of visual impairment as is the case here, on disfigurement under Diagnostic Code 7800. Similarly, under Diagnostic Code 6037, pinguecula is rated based on disfigurement under Diagnostic Code 7800. For a 10 percent rating under Diagnostic Code 7800, there must be at least one of the eight characteristics of disfigurement. The eight characteristics are: a scar five or more inches in length, scar at least one-quarter inch wide at widest part, surface contour of scar elevated or depressed on palpation, scar adherent to underlying tissue, skin hypo- or hyper-pigmented in an area exceeding six square inches, skin texture abnormal in an area exceeding six square inches, underling soft tissue missing in an area exceeding six square inches, and skin indurated and inflexible in an area exceeding six square inches. Here, the Veteran’s ptosis and pinguecula have not been noted to cause any of the eight characteristics. As such, separate ratings for asymmetry of the eyes caused by ptosis and/or pinguecula are not warranted. In sum, for the entire period of appeal, a schedular rating in excess of 10 percent for the left eye conjunctivitis/ptosis under Diagnostic Code 6018 is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder is remanded. In November 2016, a private psychologist, Dr. H.H., completed a mental disorders disability benefits questionnaire on the Veteran. She diagnosed the Veteran with unspecified depressive disorder and opined that the depressive disorder more likely than not began in military service and continued uninterrupted to the present. The Board finds that Dr. H.H.’s opinion is not a sufficient basis on which to determine whether any diagnosed acquired psychiatric disorder is related to the Veteran’s active service. Except for noting three lay statements submitted by the Veteran’s family members, Dr. H.H. did not provide an explanation or rationale for her conclusion that the Veteran’s depression was related to service. Thus, the Board finds that a VA medical examination and medical opinion is necessary. 2. Entitlement to service connection for headaches is remanded. In January 2017, a private physician, Dr. H.S., completed a headaches disability questionnaire on the Veteran. Dr. H.S. opined that the headaches were more likely than not caused by and permanently aggravated by the Veteran’s depressive disorder. As such, this claim is inextricably intertwined with the issue of service connection for an acquired psychiatric disorder. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered); Ephraim v. Brown, 5 Vet. App. 549, 550 (1993) (inextricably intertwined claims should be remanded together). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA psychiatric examination with a psychiatrist or psychologist to determine the current nature and likely etiology of any diagnosed psychiatric disability, to include unspecified depressive disorder. The entire claims file, including a copy of this REMAND, must be reviewed by the examiner in conjunction with the examination. All indicated studies, tests, and evaluations deemed necessary should be performed. The examiner should note all psychiatric diagnoses. For each diagnosed psychiatric disability, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that disability was incurred in or aggravated by service. A thorough rationale should be provided for all opinions expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. 2. After completing all indicated development, and any additional development deemed necessary, readjudicate the claims in light of all the evidence of record. If any benefit sought on appeal remains denied, then a fully responsive supplemental statement of the case should be   furnished to the Veteran and his representative and they should be afforded a reasonable opportunity for response. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Nelson, Counsel