Citation Nr: 18158897 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 16-30 488 DATE: December 19, 2018 ORDER The petition to reopen a claim of entitlement to service connection for gout is denied. The petition to reopen a claim of entitlement to service connection for lumbar spine disability is denied. The petition to reopen a claim of entitlement to service connection for hypertension is denied. The petition to reopen a claim of entitlement to service connection for diabetes mellitus is denied. The petition to reopen a claim of entitlement to service connection for a disability claimed as “arthritis throughout most of body” is denied. The petition to reopen a claim of entitlement to service connection for asthma is denied. The petition to reopen a claim of entitlement to service connection for a psychiatric disorder, variously diagnosed and claimed as posttraumatic stress disorder (PTSD), is granted. The petition to reopen a claim of entitlement to service connection for sleep apnea is granted. The claim of entitlement to service connection for tinnitus is denied. The claim of entitlement to service connection for a right hip disability is denied. The claim of entitlement to service connection for a left hip disability is denied. The claim of entitlement to service connection for sleep apnea is granted. The claim of entitlement to a compensable rating for surgical scars of the left knee is denied. REMANDED The claim of entitlement to service connection for a psychiatric disorder, variously diagnosed, is remanded. The claim of entitlement to service connection for insomnia is remanded. The claim of entitlement to service connection for a right ankle disability is remanded. The claim of entitlement to service connection for a left ankle disability is remanded. The claim of entitlement to a rating in excess of 10 percent for degenerative joint disease of the left knee is remanded. The claim of entitlement to a rating in excess of 10 percent for chronic strain of the right knee is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s claim of entitlement to service connection for gout was denied by a January 2013 RO rating decision. The appellant was notified of the decision and initiated an appeal, but did not perfect the appeal following issuance of a May 2015 statement of the case. The Veteran did not otherwise submit new and material evidence within one year following the rating decision beyond that considered in the May 2015 readjudication for the statement of the case. 2. All of the evidence submitted since the January 2013 RO rating decision pertaining to the gout issue is either cumulative and redundant or does not relate to an unestablished fact necessary to substantiate the claim. 3. The Veteran’s claim of entitlement to service connection for a lumbar spine disability was denied by a January 2013 RO rating decision. The appellant was notified of the decision and initiated an appeal, but did not perfect the appeal following issuance of a May 2015 statement of the case. The Veteran did not otherwise submit new and material evidence within one year following the rating decision beyond that considered in the May 2015 readjudication for the statement of the case. 4. All of the evidence submitted since the January 2013 RO rating decision pertaining to the lumbar spine disability issue is either cumulative and redundant or does not relate to an unestablished fact necessary to substantiate the claim. 5. The Veteran’s claim of entitlement to service connection for hypertension was denied by an October 2013 RO rating decision. The appellant was notified of the decision and initiated an appeal, but did not timely perfect the appeal following issuance of an August 2015 statement of the case. The Veteran did not otherwise submit new and material evidence within one year following the rating decision beyond that considered in the August 2015 readjudication for the statement of the case. 6. All of the evidence submitted since the October 2013 RO rating decision pertaining to the hypertension issue is either cumulative and redundant or does not relate to an unestablished fact necessary to substantiate the claim. 7. The Veteran’s claim of entitlement to service connection for diabetes mellitus was denied by an October 2013 RO rating decision (following a prior denial in May 2012). The appellant was notified of the decision and initiated an appeal, but did not perfect the appeal following issuance of an August 2015 statement of the case. The Veteran did not otherwise submit new and material evidence within one year following the rating decision beyond that considered in the August 2015 readjudication for the statement of the case. 8. All of the evidence submitted since the October 2013 RO rating decision pertaining to the diabetes mellitus issue is either cumulative and redundant or does not relate to an unestablished fact necessary to substantiate the claim. 9. The Veteran’s claim of entitlement to service connection for “arthritis throughout most of body” was denied by an October 2013 RO rating decision. The appellant was notified of the decision and initiated an appeal, but did not perfect the appeal following issuance of an August 2015 statement of the case. The Veteran did not otherwise submit new and material evidence within one year following the rating decision beyond that considered in the August 2015 readjudication for the statement of the case. 10. All of the evidence submitted since the October 2013 RO rating decision pertaining to the “arthritis throughout most of body” issue is either cumulative and redundant or does not relate to an unestablished fact necessary to substantiate the claim. 11. The Veteran’s claim of entitlement to service connection for asthma was denied by an October 2013 RO rating decision. The appellant was notified of the decision and initiated an appeal, but did not perfect the appeal following issuance of an August 2015 statement of the case. The Veteran did not otherwise submit new and material evidence within one year following the rating decision beyond that considered in the August 2015 readjudication for the statement of the case. 12. All of the evidence submitted since the October 2013 RO rating decision pertaining to the asthma issue is either cumulative and redundant or does not relate to an unestablished fact necessary to substantiate the claim. 13. The Veteran’s claim of entitlement to service connection for a psychiatric disorder, claimed as PTSD, was denied by an October 2013 RO rating decision. The appellant was notified of the decision and initiated an appeal, but did not perfect the appeal following issuance of an August 2015 statement of the case. The Veteran did not otherwise submit new and material evidence within one year following the rating decision beyond that considered in the August 2015 readjudication for the statement of the case. 14. Evidence submitted since the October 2013 RO rating decision pertaining to the psychiatric disorder issue includes evidence that is not cumulative and redundant of prior evidence and relates to an unestablished fact necessary to substantiate the claim. 15. The Veteran’s claim of entitlement to service connection for sleep apnea was denied by an October 2013 RO rating decision. The appellant was notified of the decision and initiated an appeal, but did not perfect the appeal following issuance of an August 2015 statement of the case. The Veteran did not otherwise submit new and material evidence within one year following the rating decision beyond that considered in the August 2015 readjudication for the statement of the case. 16. Evidence submitted since the October 2013 RO rating decision pertaining to the sleep apnea issue includes evidence that is not cumulative and redundant of prior evidence and relates to an unestablished fact necessary to substantiate the claim. 17. The preponderance of the evidence is against finding that the Veteran’s tinnitus began during active service, or is otherwise related to an in-service injury, event, or disease. 18. The preponderance of the evidence is against finding that the Veteran has a right hip disability that began during active service, or is otherwise related to an in-service injury, event, or disease. 19. The preponderance of the evidence is against finding that the Veteran has a left hip disability that began during active service, or is otherwise related to an in-service injury, event, or disease. 20. Resolving reasonable doubt in the Veteran’s favor, the evidence shows that the Veteran’s sleep apnea is proximately due to medical treatment for his service-connected knee disabilities. 21. The preponderance of the evidence of record is against finding that the Veteran’s service-connected surgical scarring of the left knee is unstable and/or painful; is deep and nonlinear or associated with soft tissue damage; involves an area of at least 6 square inches (39 sq. cm.) or greater; or causes any other disabling effect such as limitation of function of the affected body part. CONCLUSIONS OF LAW 1. The criteria for reopening the claim of entitlement to service connection for gout have not been satisfied. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 2. The criteria for reopening the claim of entitlement to service connection for a lumbar spine disability have not been satisfied. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 3. The criteria for reopening the claim of entitlement to service connection for hypertension have not been satisfied. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 4. The criteria for reopening the claim of entitlement to service connection for diabetes mellitus have not been satisfied. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 5. The criteria for reopening the claim of entitlement to service connection for a disability claimed as “arthritis throughout most of body” have not been satisfied. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 6. The criteria for reopening the claim of entitlement to service connection for asthma have not been satisfied. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 7. The criteria for reopening the claim of entitlement to service connection for a psychiatric disorder, claimed as PTSD, have been satisfied. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 8. The criteria for reopening the claim of entitlement to service connection for sleep apnea have been satisfied. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156. 9. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 10. The criteria for entitlement to service connection for a right hip disability are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 11. The criteria for entitlement to service connection for a left hip disability are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 12. The criteria for entitlement to secondary service connection for sleep apnea are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). 13. The criteria for a compensable disability rating for service-connected surgical scars of the left knee have not been met. 38 U.S.C. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, and 4.118, Diagnostic Codes 7801-7805; 38 Fed. Reg. 32592. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1997 to December 1999. This case comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Offices (ROs) dated in September 2015 and May 2016. The Board notes that the Veteran had previously initiated appeals for a number of issues, including issues featuring disabilities and rating currently in appellate status before the Board. In May 2015 and in August 2015, the Agency of Original Jurisdiction (AOJ) issued formal statements of the case (SOCs) addressing those past appeals. The latter of these two SOCs was issued on August 11, 2015. The Veteran submitted a VA Form 9 Substantive Appeal that was signed and dated on October 26, 2015, and received by VA on October 31, 2015. In general, except in the case of simultaneously contested claims, a Substantive Appeal must be filed within 60 days from the date that the AOJ mails the Statement of the Case to the appellant, or within the remainder of the 1-year period from the date of mailing of the notification of the determination being appealed, whichever period ends later. 38 C.F.R. § 20.302. The ratings decisions / determinations pertinent to those appeals were issued in 2013, and the VA Form 9 received on October 31, 2015, was filed more than a year after the rating decisions and more than 60 days following the SOCs. Although a September 2015 RO rating decision adjudicated certain issues that were similar / overlapping with issues addressed in the May 2015 SOC, the allotted period for perfecting an appeal from the May 2015 SOC had already expired and that appeal stream was closed. The September 2015 RO rating decision did not pertain to the matters addressed in the August 2015 SOC. The October 2015 VA Form 9 was not timely to perfect an appeal on any issue. None of the appeals initiated and addressed in the May and August 2015 SOCs were timely perfected for Board review, and the appeals before the Board at this time do not arise from those SOCs. The Veteran’s request for a Board hearing presented on the October 2015 VA Form 9 was not valid as the VA Form 9 was not a timely substantive appeal on any issue. The Board notes that the Veteran has since perfected appeals on the matters currently before the Board and addressed in this decision, and the Veteran’s timely VA Form 9 substantive appeals pertaining to the current appeals expressly declined to request a Board hearing on any matter. Thus, there is no request for a Board hearing associated with the appeals currently before the Board for appellate review. Service Connection Petitions to Reopen Previously Denied Claims 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 U.S.C. § 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). The United States Court of Appeals for Veterans Claims (Court) has held that the phrase ‘raises a reasonable possibility of establishing the claim’ must be viewed as enabling rather than precluding reopening. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). When determining whether a claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510 (1992). 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 (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 should ask whether the evidence could reasonably substantiate the claim were 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. A claimant may submit an application or claim to reopen a disallowed claim, when VA must provide some limited assistance. See Paralyzed Veterans of America v. Secretary of Veterans Affairs, 345 F.3d 1334, 1341 (Fed. Cir. 2003) (VA will perform document gathering assistance even before claim is reopened); see 38 C.F.R. § 3.159(c)(1)-(3). Absent the submission of evidence that is sufficient to reopen the claim, the Board’s analysis must cease. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996); Butler v. Brown, 9 Vet. App. 167, 171 (1996); McGinnis v. Brown, 4 Vet. App. 239, 244 (1993). The Board may not then proceed to review the issue of whether the duty to assist has been fulfilled, or undertake an examination of the merits of the claim. Regardless of whether the RO found new and material evidence to reopen a claim, the Board is not bound by such a determination and must nevertheless consider whether new and material evidence has been received. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). The Board will therefore undertake a de novo review of the new and material evidence determinations required to resolve the Veteran’s petitions to reopen the claims of entitlement to service connection. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Disorders diagnosed after discharge may still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection for the claimed disorder, there must be evidence of (1) a current disability, (2) incurrence or aggravation of a disease or injury in service, and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Board notes that it has reviewed all of the evidence in the Veteran’s claims file, including in VA’s electronic data storage system, with an emphasis on the evidence relevant to this appeal. Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss every piece of evidence of record in detail. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. A May 2012 RO rating decision denied service connection for diabetes mellitus. The basis of the denial of service connection for diabetes, including as explained in the cover letter accompanying the rating decision’s issuance in June 2012, featured the RO’s finding that the evidence did not show that the Veteran’s diabetes had been diagnosed during service or within a year thereafter, and the RO found that the evidence did not otherwise indicate that the Veteran’s diabetes was related to his military service. The Veteran did not timely appeal the May 2012 denial, as no notice of disagreement was filed within a year of the decision’s issuance. See 38 C.F.R. § 20.302(a). No new and material evidence pertinent to this issue was submitted within a year following the May 2012 denial of the claim. 38 C.F.R. § 3.156(b). The May 2012 RO denial is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104(a), 20.302. An October 2013 RO rating decision denied service connection for PTSD / psychiatric disorder, sleep apnea, hypertension, “arthritis throughout most of body,” asthma, and diabetes. The basis of the denial of service connection for each of these claimed disabilities featured the RO’s finding that the evidence did not show that the claimed disabilities were related to his military service. The RO’s decision also cited that the evidence did not show that the Veteran had been diagnosed with a disability corresponding to his claimed “arthritis throughout most of body. The Veteran initiated an appeal of the denials of the service connection claims in the October 2013 RO rating decision; the claims were readjudicated with the issuance of a statement of the case in August 2015. The Veteran did not perfect that appeal for further review. No new and material evidence was submitted within a year of the denial of the claim. 38 C.F.R. § 3.156(b). (The Veteran’s correspondence citing his back and knee pains in connection with his psychiatric disorder in July 2014 was considered in the August 2015 readjudication for the statement of the case, and the evidence was not new and material as the Veteran’s difficulties with his back and knees were already established in the record.) The October 2013 RO denial is final with regard to the issues of entitlement to service connection for PTSD / psychiatric disorder, sleep apnea, hypertension, “arthritis throughout most of body,” asthma, and diabetes. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104(a), 20.302. A January 2013 RO rating decision denied service connection for gout and for lumbar spine disability. The basis of the denial of service connection for each of these claimed disabilities featured the RO’s finding that the evidence did not show that the claimed disabilities were related to his military service. The RO’s decision cited a VA medical opinion of record that indicated that the Veteran’s current back disability was not medically / etiologically linked to his in-service complaints of back symptoms. The Veteran initiated an appeal of the denials of the service connection claims in the January 2013 RO rating decision; the claims were readjudicated with the issuance of a statement of the case in May 2015. The Veteran did not perfect that appeal for further review. No new and material evidence was submitted within a year of the denial of the claim. 38 C.F.R. § 3.156(b). The January 2013 RO denial is final with regard to the issues of entitlement to service connection for gout and for lumbar spine disability. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104(a), 20.302. In June 2015, the Veteran filed a petition to reopen the previously denied claims of entitlement to service connection for PTSD / psychiatric disorder, sleep apnea, hypertension, “arthritis throughout most of body,” asthma, diabetes, gout, and lumbar spine disability. 1. The petition to reopen a claim of entitlement to service connection for gout is denied. 2. The petition to reopen a claim of entitlement to service connection for lumbar spine disability is denied. 3. The petition to reopen a claim of entitlement to service connection for hypertension is denied. 4. The petition to reopen a claim of entitlement to service connection for diabetes mellitus is denied. 5. The petition to reopen a claim of entitlement to service connection for a disability claimed as “arthritis throughout most of body” is denied. 6. The petition to reopen a claim of entitlement to service connection for asthma is denied. At the time of the prior final May 2012 and January 2013 decisions, the evidentiary record featured service treatment records and post-service medical records. Since the time of the prior final decisions, additional documents and medical evidence contain further documentation for treatment of claimed disabilities; there continues to be no documentation of a corresponding medical diagnosis for the Veteran’s claimed “arthritis throughout most of body.” The new evidence does not include any indication of in-service onset or other manner of nexus between the Veteran’s current claimed disabilities and the Veteran’s military service. No new medical evidence or testimony has indicated any basis for finding a causal / etiological link between the Veteran’s claimed disabilities and his military service. The new evidence does not tend to establish any previously unestablished element of entitlement to service connection for hypertension, “arthritis throughout most of body,” asthma, diabetes, gout, or lumbar spine disability. The Veteran has not otherwise presented any testimony or evidence that indicates any pertinent new information or development that would tend to establish a previously unestablished element of entitlement to service connection for hypertension, “arthritis throughout most of body,” asthma, diabetes, gout, or lumbar spine disability. Accordingly, evidence added to the record after the prior final denial of each issue may be new, but it is not material to these issues. The evidence added to the record since the prior final denial of each issue presents no reasonable possibility of substantiating the claims, and such evidence is not new and material for the purpose of reopening these claims. Following review of the contents of the claims-file, the Board is unable to find that any item of evidence received since the prior final denials of each issue is new and material to the issues of entitlement to service connection for hypertension, “arthritis throughout most of body,” asthma, diabetes, gout, or lumbar spine disability. Any added material evidence is duplicative of evidence already of record, and the new evidence is not materially pertinent to elements of service connection that were unestablished at the time of the prior final denial for each issue. The prior final denials were based upon the absence of a showing of a nexus between military service and the claimed disabilities, as well as the absence of a diagnosed disability corresponding to the claimed “arthritis throughout most of body.” None of the evidence submitted after the prior final denial for each claim tends to establish such a nexus, nor does any evidence tend to establish a medical disability corresponding to “arthritis throughout most of body.” The added evidence simply confirms the existence of previously established disabilities; the added evidence does not indicate that any of the claimed current disabilities had onset during service or are otherwise etiologically / causally related to any aspect of military service. Overall, the Board finds that the new evidence does not relate to an unestablished fact necessary to substantiate the Veteran’s claims of entitlement to service connection for hypertension, “arthritis throughout most of body,” asthma, diabetes, gout, or lumbar spine disability. For the above-discussed reasons, the Board concludes that the appellant has not presented new and material evidence to reopen his claims for service connection for hypertension, “arthritis throughout most of body,” asthma, diabetes, gout, or lumbar spine disability. Accordingly, the petition to reopen each of these claims must be denied. See 38 U.S.C. § 5108. New and material evidence has not been received, and the claims of entitlement to service connection for hypertension, “arthritis throughout most of body,” asthma, diabetes, gout, or lumbar spine disability may not be reopened. 7. The petition to reopen a claim of entitlement to service connection for a psychiatric disorder, variously diagnosed and claimed as posttraumatic stress disorder (PTSD), is granted. 8. The petition to reopen a claim of entitlement to service connection for sleep apnea is granted. The Board finds that new and material evidence has been received to reopen the claims of entitlement to service connection for a psychiatric disorder and for sleep apnea. Specifically, the new and material evidence includes (1) a November 2016 private medical opinion that concludes that the Veteran’s “depressive disorder with anxious distress features is as [sic] more likely than not aggravated by his service connected medical conditions….,” and (2) a December 2016 private medical opinion that concludes that “the veteran’s opioid medication for pain caused by his service connected impairments and depressive disorder aided in the development of and permanently aggravates his OSA [obstructive sleep apnea].” The Board finds that new and material evidence has been submitted on the issues of entitlement to service connection for the Veteran’s psychiatric disorder and his sleep apnea, following the prior final denial of these claims. Accordingly, the Board has reopened the claims of entitlement to service connection for psychiatric disorder and sleep apnea for consideration on the merits at this time. 9. The claim of entitlement to service connection for tinnitus is denied. 10. The claim of entitlement to service connection for a right hip disability is denied. 11. The claim of entitlement to service connection for a left hip disability is denied. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Certain chronic diseases, including arthritis and tinnitus (as an organic disease of the nervous system), may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran contends that he suffers from tinnitus and disabilities of the right and left hips due to his military service. The question for the Board in each of these issues is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Hips The Board observes that VA medical records from July 2012 indicate that the Veteran’s complaints of knee pains led his treatment providers to order X-ray imaging studies that included “pelvis” in order to “rule out hip problems.” The diagnostic evaluation revealed no significant abnormality. It is not clear from the medical evidence of record that the Veteran has a disability of either hip. However, even if the Veteran has a current hip disability, the preponderance of the evidence weighs against finding that any such disability began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). In this regard, the Board notes that the Veteran’s service treatment records contain no reference to hip problems during service and no suggestion of any diagnosis involving the hips. Furthermore, the September 1999 medical examination report associated with the conclusion of the Veteran’s period of active duty service shows no suggestion of any clinical abnormality of either hip upon complete examination, and the Veteran made no suggestion of any hip problems amongst his identified medical concerns and symptoms noted in the medical history questionnaire. At that time, the Veteran expressed a desire to seek treatment for pain in his knees, feet, and back, with no suggestion of hip problems. The Veteran filed the claim for service connection for the claimed hip disabilities in May 2015, more than 15 years after separation from service, and the evidence in this case (including medical evidence) contains no indication of onset of a hip disability during service, within a year of service, or otherwise proximate to the Veteran’s military service. The lapse of time between service separation and the earliest documentation of current disability may be a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). There is no medical opinion or competent medical evidence of record indicating that the Veteran suffers from any hip disability causally / etiologically linked to his military service. The only information of record suggesting that the Veteran has a hip disability causally / etiologically linked to his military service is the Veteran’s own assertion that he has a service-connected disability of both hips. While the Veteran is competent to report his symptoms of a hip disability, as a layperson he is not competent to provide a diagnosis or etiology of the claimed hip disabilities. The issue is medically complex, as it requires knowledge of the non-apparent features of hip structure, joint degeneration, the muscles, the effect of age and injury on the body, and other factors. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board finds that the preponderance of the evidence is against the claims of entitlement to service connection for disabilities of the right and left hips. As the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Accordingly, the claims must be denied. Tinnitus The Board concludes that, while the Veteran has a current diagnosis of tinnitus, the preponderance of the evidence weighs against finding that the Veteran’s current disability began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Board notes that the evidence establishes that the Veteran was exposed to hazardous levels of noise during service, as his service treatment records include documentation of multiple audiology / audiometric evaluations that clearly note that special monitoring of his ear/hearing health was conducted due to his hazardous noise exposure. None of the service treatment records indicate that any pertinent clinical abnormality was detected concerning the Veteran’s hearing or ears, and no complaint or diagnosis of tinnitus was ever noted during service. The Veteran underwent ear / hearing testing in addition to a complete medical examination in September 1999 in association with the conclusion of his active duty service. At that time, medical professionals determined that the Veteran’s ears were clinically normal with no pertinent abnormalities and no suggestion of tinnitus (or hearing loss). The Board finds it reasonable to expect that the heightened attention to evaluation of the Veteran’s hearing health during service would include notation of tinnitus (as a disorder of hearing sensation) if the Veteran were experiencing tinnitus during service. The Veteran’s VA medical records document that in June 2001 the Veteran sought treatment for hearing loss that he reported having “since 1998 which he attributes to noise exposure in the service,” and at that time the Veteran described “periodic tinnitus, left ear worse than right ear, which he noticed during basic training when firing Howitzers.” Thus, the evidence from during and proximate to the Veteran’s period of service does not show chronic tinnitus during service or within a year following service, and the evidence from June 2001 shows “periodic” tinnitus that the Veteran described as dating back to his military service. The Board finds that the evidence does not show chronic tinnitus during service or within a year thereafter in a manner that would establish entitlement to service connection for his post-service diagnosis of tinnitus on the basis of the provisions concerning chronic diseases under 38 C.F.R. §§ 3.303(b), 3.307(a)(3), and 3.309(a). The Board must now consider whether a continuity of symptomatology or other showing of an etiological link is shown in this case to establish entitlement to service connection for the Veteran’s post-service diagnosis of tinnitus. The claims file includes an August 2015 VA audiology examination report with medical opinion informed by review of the claims file along with examination and interview of the Veteran. The examining audiologist opined that the Veteran’s tinnitus is “[l]ess likely than not (less than 50% probability) caused by or a result of military noise exposure.” The VA audiologist considered the pertinent evidence, discussing the Veteran’s report that he first recalled onset of tinnitus “[d]uring military service from noise exposure,” and noted that the “[s]ervice treatment records do not show any complaints of tinnitus or hearing loss.” The Board understands the VA audiologist’s opinion as indicating that in the absence of medical detection of any hearing loss or tinnitus during service (including with the heightened monitoring of the Veteran’s hearing health associated with his recognized hazardous noise exposure), it is unlikely any ringing in his ears that he recalls occurring during service was a manifestation of a chronic pathology associated with his current tinnitus. The Board finds that the August 2015 VA audiology expert’s opinion in this regard is competent evidence concerning the degree of probability that the Veteran’s in-service noise exposure and any recalled episodes of ringing in his ears during service are causally / etiologically linked to his post-service tinnitus. The Board finds that the August 2015 VA audiology opinion is probative evidence weighing against the claim of entitlement to service connection for tinnitus. The August 2015 VA examiner’s opinion is based on an accurate factual predicate and provides an explanation that contains clear conclusions consistent with supporting data in the cited medical history. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran’s statements in this case have repeatedly indicated that he recalls onset of tinnitus symptoms during service. They might also be understood to suggest a continuity of symptomatology since an in-service onset. The probative contemporaneous service treatment records contradict such a suggestion of continuity, in that they contain documentation of heightened medical monitoring of his hearing sensory health during service with no indication of hearing loss, tinnitus, or other symptoms or abnormality of his hearing sensory system. To the extent the Veteran may be asserting in-service onset of tinnitus with a continuity of symptomatology thereafter, his statements are inconsistent with the contemporaneous evidence of record from his time of service. Thus, the Board finds that any statement as to symptoms of chronic tinnitus beginning during service and persisting continuously since that time are less than credible. In making such a credibility finding, the Board is not necessarily finding that the Veteran has any intent to deceive. Rather, he may be simply mistaken in his recollections due to the fallibility of human memory for events that occurred many years ago. The Board finds that, if the Veteran had had symptoms of chronic tinnitus during service, it would be reasonable to expect that he would have reported the symptoms to medical professionals in connection with the heightened in-service medical attention paid to monitoring the health of his hearing due to his in-service hazardous noise exposure. However, there is no such notation in his service treatment records. The Veteran’s September 1999 Report of Medical History reflects that he specifically denied having any history of hearing loss, and he otherwise made no suggestion of ringing in his ears or tinnitus amongst the health concerns he did report experiencing. The September 1999 medical examination reports show that clinical examination of his ears revealed no abnormality, including with audiometric testing. This includes the Veteran’s September 1999 final routine examination report and his September 1999 final “Hearing Conservation” audiology examination report. The Board finds that the contemporaneous service treatment records are probative evidence indicating that the Veteran did not have tinnitus when his ear / hearing health was examined by medical professionals, including audiology specialists, monitoring for potential problems from hazardous noise exposure during service. The Veteran is competent to report having experienced acoustic trauma and symptoms such as the perception of ringing in his ears currently and during service. As discussed above, the Board finds that the Veteran’s report of experiencing onset of tinnitus during service is not credible due to the contrary probative contemporaneous evidence. The Veteran is otherwise not competent to establish the likelihood of a medical etiological link between the Veteran in-service experiences and acoustic trauma and his post-service tinnitus that was first noted more than a year following service. The question of etiology is medically complex, as it requires knowledge of the organs of hearing sensation including with regard to nerve function and damage over time. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The most probative evidence of record features the contemporaneous service records showing that heightened attention was paid to the Veteran’s hearing sensory health and that no suggestion of tinnitus was ever noted during service. There is no contemporaneous evidence of onset of tinnitus for more than a year following service. The Veteran’s statements assert an in-service onset of tinnitus based on his recollections in hindsight, but contrary to the more probative contemporaneous medical reports from the monitoring of his hearing health. The Board finds that the most probative evidence weighs against finding that the Veteran had onset of tinnitus during service, or within a year following service, with continuity of symptomatology thereafter. The August 2015 VA audiology examination report presents a probative medical opinion indicating that a link between the Veteran’s in-service experiences and his post-service diagnosis of tinnitus is unlikely. There is no contrary medical opinion of record, nor is there otherwise competent evidence indicating that the Veteran’s tinnitus is causally / etiologically linked to his military service. Accordingly, the August 2015 VA audiology opinion is persuasive. The Board finds that the preponderance of the evidence is against finding that the Veteran’s post-service diagnosed tinnitus is etiologically linked to his military service. The Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for tinnitus. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Accordingly, the claim must be denied. 12. The claim of entitlement to service connection for sleep apnea is granted. Resolving reasonable doubt in the Veteran’s favor, the Board finds that his sleep apnea is proximately due to prescribed medications for treatment of his service-connected knee disabilities. Service connection may be granted for a disability due to disease or injury incurred in or aggravated by military service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. Service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). To establish entitlement to service connection on a secondary basis, there must be competent medical evidence of record establishing that a current disability is proximately due to or the result of a service-connected disability. See Lathan v. Brown, 7 Vet. App. 359, 365 (1995). Further, a disability that is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439 (1995). 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. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). A December 2016 medical opinion from a private physician, informed by review of the Veteran’s documented medical history, explains: “The Veteran treats his service connected left and right knees with hydrocodone and tizanidine. Hydrocodone is an opiate which is a class of medication often used for pain relief …. Opioids result in increased respiratory pauses, irregular breathing, and shallow breaths.” The December 2016 opinion further explains: “Medical literature states abnormal sleep architecture has been reported during the process of opioids induction, maintenance, and withdrawal.” Additionally, the private opinion explains: “Opiates are recognized respiratory depressants that cause abnormal ventilator responses to hypercapnia and hypoxia. Tizanidine is a muscle relaxant. Muscle relaxers relax the muscles in a patient’s throat and are known to aggravate sleep apnea.” On the basis of such information in addition to discussion of the Veteran’s medical history, the December 2016 private medical opinion concludes: “Based on the above medical literature, interview with the veteran …, and review of the veteran’s claims file, it is my opinion that veteran’s opioid medication for pain caused by his service connected impairments and depressive disorder aided in the development of and permanently aggravates his OSA [obstructive sleep apnea].” The Board notes that the December 2016 medical opinion suggests that the Veteran’s non-service-connected (pending appeal) psychiatric disorder has played a role in the causation of sleep apnea, and that the treatment of the service-connected knee disabilities “aided in the development of” the sleep apnea. Although the extent of the role played by the service-connected knee disabilities is not unequivocally clear, the Board finds that the December 2016 private medical opinion reasonably indicates that the obstructive sleep apnea is causally linked to medical treatment that features the Veteran’s service-connected knee disabilities, even if not exclusively featuring those service-connected disabilities. The Board has considered whether a remand for additional development may be necessary in this case. However, the Board finds that the available information permits the Board to grant service connection for sleep apnea with resolution of reasonable doubt in the Veteran’s favor. An award of service connection for sleep apnea in this case does not require a demonstration that the service-connected knee disabilities be the only cause of the sleep apnea. Under the circumstances of this case, the Board finds that the information presented in the December 2016 private medical opinion indicates that the Veteran’s service-connected knee disabilities and associated prescribed medications are significant to the multifactorial causation of his sleep apnea. The Board finds that the December 2016 private medical opinion is adequately informed and explained, with a persuasive rationale presented by a competent medical expert. Accordingly, it is probative evidence weighing in support of the claim of entitlement to service connection for sleep apnea. As there is no significantly contrary medical opinion of record or other manner of evidence indicating that the Veteran’s sleep apnea is not causally linked to the cited medications prescribed in connection with the service-connected knee disabilities, the December 2016 private medical opinion is persuasive. On this basis, the Board is able to resolve reasonable doubt in the Veteran’s favor and grant service connection for sleep apnea. Service connection for sleep apnea is warranted. 13. The claim of entitlement to a compensable rating for surgical scars of the left knee is denied. The Veteran has appealed for compensable disability ratings for service-connected surgical scars of his left knee area. The Veteran’s left knee surgical scarring on appeal is currently assigned a noncompensable rating under 38 C.F.R. § 4.118, Diagnostic Code 7805, effective from September 28, 2012. Diagnostic Code 7805 provides that scars and other effects of scars are to be evaluated under Codes 7800, 7801, 7802, and 7804, or under another appropriate code if such disabling effects are not considered under Codes 7800, 7801, 7802, or 7804. The Board notes that, effective August 13, 2018, VA has revised 38 C.F.R. § 4.118. These revisions apply to all claims filed on or after August 13, 2018. As to claims filed prior to and pending on August 13, 2018, they are to be considered under both the old and new rating criteria and whatever criteria is more favorable to the veteran will be applied. 83 Fed. Reg. 32592. As to the Veteran’s scars on appeal, the Board has considered Diagnostic Codes 7800 through 7805 for potential application in rating the disability. A review of the newly revised rating criteria for scars shows that, essentially, only Diagnostic Codes 7801 and 7802 were revised. Under the old rating criteria, Diagnostic Code 7801 provided that burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrant a 10 percent rating. A 20 percent rating requires an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A 30 percent rating requires an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.). A 40 percent rating requires an area or areas of 144 square inches (929 sq. cm.) or greater. A qualifying scar is one that is nonlinear and deep, and is not located on the head, face, or neck. Note (1) to Diagnostic Code 7801 provides that a deep scar is one associated with underlying tissue damage. 38 C.F.R. § 4.118. The revised criteria change the requirement that the scar be “deep and nonlinear” to “associated with underlying soft tissue damage.” Otherwise, the rating criteria remain the same. 83 Fed. Reg. at 32598. Under the old criteria, Diagnostic Code 7802 provided that burn scars or scars due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent evaluation. Note (1) to Diagnostic Code 7802 provides that a superficial scar is one not associated with underlying soft tissue damage. Note (2) to Diagnostic Code 7802 provides that if multiple qualifying scars are present, a separate evaluation is assigned for each affected extremity based on the total area of the qualifying scars that affect that extremity. 38 C.F.R. § 4.118. The new rating criteria require the scar be “not associated with underlying soft tissue damage” rather than be “superficial and nonlinear.” 83 Fed. Reg. at 32598. The only other revisions to Diagnostic Codes 7801 and 7802 are that the associated notes were revised. Note (1) now defines six zones of the body as each extremity, anterior trunk, and posterior trunk; and states that the midaxillary line divides the anterior trunk from the posterior trunk. Note (2) states that a separate rating may be assigned for each affected zone of the body under this Diagnostic Code if there are multiple scars, or a single scar, affecting multiple zones of the body. Separate ratings should be combined under 38 C.F.R. § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under the DC. Id. The rating criteria under Diagnostic Codes 7800, 7804, and 7805, were not changed in the new revisions (only the header of Diagnostic Code 7805 was revised). Diagnostic Code 7800 provides ratings for scars or disfigurement of the head, face, or neck. As all of the Veteran’s surgical scarring for consideration in this appeal is of the left knee, none of the scarring involves the head, face, or neck. Accordingly, Diagnostic Code 7800 does not provide any basis for assignment of compensable ratings in this case, and further discussion of Diagnostic Code 7800 is unnecessary. Diagnostic Code 7804 provides a 10 percent rating for 1 or 2 scars that are unstable or painful. A 20 percent rating is warranted for 3 to 4 scars that are unstable or painful and a 30 percent disability rating assigned for 5 or more scars that are unstable or painful. Note (1) to Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. Diagnostic Code 7805 provides that other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800-04 require the evaluation of any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate diagnostic code. Id. The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The Board must consider whether a higher rating is warranted under any other applicable Diagnostic Code or permitted combination of separate ratings under multiple Diagnostic Codes. Assigning separate compensable ratings for the same symptoms/functional impairment under different diagnoses would violate the prohibition against pyramiding in 38 C.F.R. § 4.14. In this case, notes to several of the applicable Diagnostic Codes expressly permit certain particular combinations of skin ratings as not violating the prohibition against pyramiding, with separate skin ratings assigned and combined with application of 38 C.F.R. § 4.25 in certain circumstances. The Board must consider whether a combination of separate ratings under the pertinent skin disability Diagnostic Codes (generally, Diagnostic Codes 7800-7805) would be more favorable to the Veteran than assignment of a single rating under another applicable Diagnostic Code. In every instance where the schedule does not provide a 0 percent rating for a diagnostic code, a 0 percent rating will be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. A September 2014 VA examination report describes the Veteran’s pertinent scarring in detail. The VA examiner described the totality of the Veteran’s left knee scarring as involving no painful scars and no unstable scars. The report describes that the scarring features a total of four scars, each one being linear and measured as 3.0 centimeters long. The September 2014 VA examination report’s presentation of clinical findings and measurements characterizing the left knee scars is competent evidence from a medical professional and is not substantively contradicted by any other evidence of record. The Board finds that the detailed characterization of the scarring in the September 2014 VA examination report is adequate and probative evidence describing the scars. These findings do not indicate that the criteria for a compensable rating have been met under any applicable Diagnostic Code. Diagnostic Code 7800 only applies to scarring of the head, face, or neck, and thus does not apply to the scarring of the left knee. The Veteran’s left knee scarring fails to meet the criteria for a compensable rating under Diagnostic Code 7801 because the totality of the Veteran’s scarring features linear scars, with no non-linear scars; Diagnostic Code 7801 does not provide any compensable rating for linear scars. Furthermore, all of the Veteran’s scars of the left knee were found to be non-deep by the September 2014 VA examiner; Diagnostic Code 7801 does not provide any compensable rating for scars that are non-deep. The Board notes that even if the scarring were to involve underlying soft tissue damage, as contemplated by the revised criteria of Diagnostic Code 7801, the Veteran’s left knee scarring does not meet the minimum requirements for a compensable rating under either version of Diagnostic Code 7801 because they are linear scars and fail to meet the area requirement for a compensable rating. The Veteran’s service-connected left knee scarring fails to meet the criteria for a compensable rating under Diagnostic Code 7802 because the totality of the Veteran’s left knee scarring features only linear scars. The scarring clearly cannot meet the minimum area requirement of 929 square centimeters for a compensable rating under this Diagnostic Code under either the new or old version. Diagnostic Code 7802 does not provide any compensable rating for linear scars. The Veteran’s service-connected left knee scarring fails to meet the criteria for a compensable rating under Diagnostic Code 7804 because all of the Veteran’s pertinent scarring has been medically determined to be not painful and not unstable. Diagnostic Code 7804 provides compensable ratings only for scars that are unstable or painful. The Veteran’s service-connected left knee scarring fails to meet the criteria for a compensable rating under Diagnostic Code 7805 because no other manner of compensable functional impairment has been shown to result from any of the service-connected scarring. The September 2014 VA examiner described the scarring as “No” functional impact upon the Veteran’s ability to work, and explained that they are “very faint” with “No” manner of “other pertinent physical findings, complications, conditions, signs and/or symptoms (such as muscle or nerve damage) associated with any scar….” These findings do not indicate that the criteria for a compensable rating have been met under any applicable Diagnostic Code. Additional references to the Veteran’s scars are presented in additional evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. The additional evidence of record does not present findings concerning the Veteran’s scars that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. Based on this evidence, the Board finds that the preponderance of the evidence is against finding that a compensable disability rating is warranted for the Veteran’s scars on appeal under either the old or new rating criteria. The Board finds the clinical medical evidence provided in the VA examination report and the Veteran’s own testimony to be probative for rating purposes. The evidence is against a finding that the Veteran’s left knee scarring has manifested in the severity of impairment contemplated by the criteria for compensable ratings, nor has any of the scarring most nearly approximated the impairment contemplated by higher ratings. The Board has considered the doctrine of affording the benefit of the doubt to the appellant, under 38 U.S.C. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Neither the Veteran nor his representative 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). REASONS FOR REMAND 1. The claim of entitlement to service connection for a psychiatric disorder, variously diagnosed, is remanded. 2. The claim of entitlement to service connection for insomnia is remanded. A private psychologist authored a November 2016 opinion in support of the Veteran’s claim for service connected disability compensation for psychiatric disorder. With this November 2016 medical opinion, the private psychologist completed a Disability Benefits Questionnaire in which he found that the Veteran’s psychiatric impairment manifested in “Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.” Symptoms included “Inability to establish and maintain effective relationships,” “Suicidal ideation,” “Persistent delusions or hallucinations,” and other indicators of severe impairment. The Board notes that a January 2014 RO rating decision formally determined that the Veteran is not competent to manage his VA payments. The November 2016 private psychologist’s opinion goes on to suggest that the Veteran is rendered unemployable by the severity of his psychiatric disorder. The high degree of reported severity of the Veteran’s mental health impairment is notable, and the November 2016 private psychologist opines that the Veteran’s “depressive disorder with anxious distress features is as [sic] more likely than not aggravated by his service connected medical conditions….” The Veteran’s only currently service-connected disabilities are degenerative joint disease of the left knee and chronic strain of the right knee, both currently rated 10 percent disabling (with the Veteran seeking higher ratings as part of this appeal, pending development of the evidence on remand). The evidence does not suggest that the Veteran’s mental health disorder was caused by his knee disabilities, but rather suggests that the Veteran’s mental health disorder has been aggravated to an unspecified degree by his knee disabilities. Noting the high degree of severity of the Veteran’s mental health impairment suggested by the evidence, the Board finds that the indication that some unspecified portion of that severity represents aggravation owing to service-connected knee disabilities is insufficiently informative to support a determination regarding entitlement to service connection at this time. 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). The Board finds that a remand for a VA examination with medical opinion to attempt to identify the degree of any aggravation, relative to a baseline, of the Veteran’s psychiatric disorder attributable to his service-connected disabilities. The Board notes that the Veteran’s appeal includes two separate certified issues that appear to involve potentially overlapping impairment: (1) entitlement to service connection for a psychiatric disorder, variously diagnosed (previously claimed as PTSD), and (2) entitlement to service connection for insomnia. The Board is here remanding these two issues together so that they may be adjudicated together. The Board also notes that the Veteran’s recent contentions in this matter suggest that his psychiatric disorder is aggravated by a number of orthopedic disabilities, and his appeals seeking (1) to establish service-connected status for disabilities of the right and left ankles, and (2) to establish that his service-connected right and left knee disabilities are more severe than contemplated by current ratings, are now pending development on remand at this time. During the processing of this remand, the AOJ shall have the opportunity to adjudicate the inextricably intertwined issues together. 3. The claim of entitlement to service connection for a right ankle disability is remanded. 4. The claim of entitlement to service connection for a left ankle disability is remanded. The Veteran has not been afforded a VA examination to assist with the claims of entitlement to service connection for disabilities of the right and left ankles, including because the RO found, as explained in the June 2016 statement of the case, that: “Your service treatment records do not show complaints … of a [left or right] ankle condition.” However, the Veteran’s September 1999 service medical assessment associated with the conclusion of the Veteran’s military service shows that the Veteran wrote that his health had recently become “worse” with reference to “knee, back, anchell [sic], + feet pain.” The Board finds that it is reasonable to read this as an indication that the Veteran was reporting ankle pain during service at that time. It is also notable that shortly after the Veteran’s separation from service, his VA medical records document evaluation for complaints of ankle strain of at least the left ankle in February 2000. The Board finds that a remand for a VA examination with medical opinion is warranted to address whether the Veteran’s claimed ankle disabilities had onset during or are otherwise etiologically related to his military service. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for right and left ankle disabilities because no VA examiner or other medical expert has opined upon this question. 5. The claim of entitlement to a rating in excess of 10 percent for degenerative joint disease of the left knee is remanded. 6. The claim of entitlement to a rating in excess of 10 percent for chronic strain of the right knee is remanded. The Veteran was afforded VA rating examinations for the purposes of rating his knee disabilities in April 2012 and September 2014. After the completion the most recent of these VA examinations, the Court has provided significant new guidance regarding the requirements of VA examination reports pertinent to this case. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” The Court found that, “to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59.” Correia, 28 Vet. App. at 169-170. The Court has also issued a significant opinion addressing whether a VA examiner is permitted to decline to offer an estimate as to additional functional loss during flare-ups if the veteran is not undergoing a flare-up at the time of the examination. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that the Board may accept a VA examiner’s assertion that he or she cannot offer such an opinion without resort to speculation only after it determines that the examiner’s conclusion is not based on the absence of procurable information or on a particular examiner’s shortcomings or general aversion to offering an opinion on issues not directly observed. It must be clear that such an opinion is not procurable based on a lack of knowledge among the “medical community at large” and not merely on a lack of expertise, insufficient information, or unprocured testing on the part of the specific examiner. The VA examination reports of record do not comply with the requirements discussed in Correia v. McDonald, 28 Vet. App. 158, 168 (2016). The VA examination reports of record also do not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). Accordingly, the Board finds that remand is necessary for a new VA examination (and to obtain a retrospective medical opinion) attempting to provide the complete information required by the Court’s holdings in Correia and Sharp. 7. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. Pending decisions on (a) the remanded issues, and (b) the pending new initial rating determinations to be made by the AOJ following from the new grant of service connection for sleep apnea, could significantly impact a decision on the issue of entitlement to a TDIU. Accordingly, the issues are inextricably intertwined. A remand of the issue of entitlement to an earlier effective date for the TDIU is required. The matters are REMANDED for the following action: 1. Associate with the claims-file any outstanding pertinent treatment records, including additional VA treatment records (such as those that may have been created since the last such update of the claims-file). 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any disability of the right and/or left ankles. The examiner must opine whether it is at least as likely as not that the Veteran has a right and/or left ankle disability that is causally / etiologically related to an in-service injury, event, or disease, including with attention to the Veteran’s report of ankle problems recorded in connection with his in-service September 1999 physical examination report. If the Veteran has arthritis of the left and/or right ankle, the examiner is asked to please opine as to whether the arthritis is at least as likely as not to have (1) begun during active service, (2) manifested within one year after discharge from service, or (3) been noted during service with continuity of the same symptomatology since service. 3. After the record is determined to be complete, schedule the Veteran for an examination of the severity of his left and right knee disabilities. (a) The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. (b) The examiner should also render, if possible to do so without resorting to mere speculation, a retrospective opinion that identifies active motion, passive motion, and pain with weight-bearing and without weight-bearing (to the extent medically appropriate) at each time the left and right knee disabilities were previously examined with documented range of motion testing for VA rating purposes. (c) The VA examiner should also express an opinion concerning whether there would be additional limits on functional ability on repeated use or during flare-ups, and, to the extent possible, provide an assessment of the functional impairment on repeated use or during flare-ups. The VA examiner should assess or estimate the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If any sought opinion cannot be provided without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. A rationale should be provided for each medical opinion presented. 4. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his psychiatric disabilities. The examiner must review the Veteran’s claims file in connection with the examination and provide an opinion responding to the following: Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s psychiatric disability has been aggravated (i.e. worsened in degree of severity) by his service-connected disabilities, particularly his service-connected knee disabilities? If the opinion is to the effect that a service-connected disability aggravated (but did not cause) a psychiatric disorder, please identify, to the extent possible, the degree of additional disability (pathology/impairment) resulting from such aggravation, indicating the “baseline” severity of such disability prior to any aggravation by a service-connected disability and the level of severity existing after the aggravation occurred. In providing this opinion, the examiner should please specifically acknowledge and discuss the November 2016 opinion of a private psychologist asserting that the Veteran’s knee disabilities have aggravated his psychiatric disability to some unspecified degree. A complete rationale for all opinions rendered must be provided. If an opinion cannot be provided without resorting to speculation, the examiner must explain why this is so and must identify what additional information, if any, would be required to provide an opinion. 5. After the above development, and any additionally indicated development, has been completed, readjudicate the issues remaining on appeal, including the inextricably intertwined issues of (a) the initial rating assignment for the newly service-connected sleep apnea disability and (b) entitlement to a TDIU. If any benefit sought on appeal is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Barone, Counsel