Citation Nr: 1807663 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 14-09 088A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for ulcers. 2. Entitlement to service connection for a chest condition. 3. Entitlement to service connection for erectile dysfunction. 4. Entitlement to an increased rating in excess of the current 10 percent rating assigned for status post left pyeloplasty with left flank pain and complex regional pain syndrome. 5. Entitlement to an initial rating in excess of 10 percent disabling for a scar associated with a left pyeloplasty. 6. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a bilateral vision condition, previously denied as a traumatic cataract condition. 7. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for chronic epistaxis and septal deviation with turbinate hypertrophy (nasal disability). 8. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a lumbar spine disability, previously denied as chronic low back pain syndrome. 9. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for chondromalacia of the right knee. 10. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a headache disability. 11. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for depression. 12. Entitlement to service connection for a cervical spine condition. 13. Entitlement to service connection for degenerative joint disease of the right shoulder. 14. Entitlement to service connection for degenerative joint disease of the left shoulder. 15. Entitlement to service connection for widespread chronic pain, also claimed as myofascial pain syndrome. 16. Entitlement to an increased rating in excess of the current 20 percent rating for degenerative changes and low-grade chondromalacia of the left knee, status post partial medial meniscectomy (a left knee disability). 17. Entitlement to service connection for chondromalacia of the right knee. 18. Entitlement to service connection for a lumbar spine disability, previously denied as chronic low back pain syndrome. 19. Entitlement to service connection for left leg pain. 20. Entitlement to service connection for hypertension. 21. Entitlement to service connection for weakness in bilateral upper extremities. 22. Entitlement to service connection for weakness in bilateral lower extremities. 23. Entitlement to service connection for an acquired psychiatric disorder. 24. Entitlement to a total disability based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and his sister ATTORNEY FOR THE BOARD Bridgid D. Houbeck, Counsel INTRODUCTION The Veteran served on active duty from December 1985 to November 1996. This matter comes to the Board of Veterans' Appeals (Board) on appeal from September 2010, November 2011, and March 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The September 2010 rating decision granted an increased rating to 10 percent for status post left pyeloplasty with left flank pain; denied an increased rating for degenerative changes and low-grade chondromalacia of the left knee, status post partial medial meniscectomy; denied the Veteran's attempts to reopen claims of service connection for degenerative joint disease of the lumbar spine, chronic epistaxis and septal deviation with turbinate hypertrophy, vision condition, right knee chondromalacia, headaches, and depression and anxiety; denied service connection for hypertension, cervical spine condition, degenerative joint disease of the right shoulder, degenerative joint disease of the left shoulder, ulcers, chest condition, left leg pain, and sexual dysfunction; and denied TDIU. The Veteran filed a notice of disagreement with that rating decision in October 2010. The November 2011 rating decision denied service connection for stress disorder, weakness of muscles in legs, chronic pain throughout the body, and weakness of the muscles in the arms. The Veteran filed a notice of disagreement with that rating decision in February 2012. The RO issued a March 2014 statement of the case on the issues of service connection for the Veteran's claims for increased ratings for left knee and left pyeloplasty; his reopened claims for service connection for vision condition, degenerative joint disease of the lumbar spine, chronic epistaxis and septal deviation with turbinate hypertrophy, right knee chondromalacia, headaches, and depression and anxiety; service connection for stress disorder, weakness of muscles in legs, chronic pain throughout the body, weakness of the muscles in the arms, hypertension, cervical spine condition, degenerative joint disease of the right shoulder, degenerative joint disease of the left shoulder, ulcers, chest condition, left leg pain, and sexual dysfunction; and denied TDIU. The Veteran perfected his appeal with a March 2014 VA Form 9. In a separate March 2014 rating decision, the RO granted service connection disabling for a scar associated with a left pyeloplasty and assigned a 10 percent rating effective July 24, 2009. In an October 2014 rating decision, the RO denied entitlement to special monthly compensation based on the need for the regular aid and attendance of another person or housebound status. In November 2014 the Veteran submitted a notice of disagreement. In an October 2017 letter, prior to the issuance of a statement of the case, the Veteran withdrew his appeal on the issue of special monthly compensation based on aid and attendance. As such, an appeal on this issue was not perfected and it is not before the Board. In May 2016, the Board remanded this case for a hearing. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge in September 2016. A transcript of the hearing is associated with the claims file. The issues of an increased rating for left knee disability; service connection for lumbar spine disability, left leg pain, hypertension, weakness in bilateral upper and lower extremities, an acquired psychiatric disorder, and a right knee disability; and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran in this case served on active duty from December 1985 to November 1996. 2. On the record at his September 2016 hearing, prior to the promulgation of a decision in the appeal, the Veteran requested a withdrawal of his appeals on the issues of service connection for ulcers, chest condition, and erectile dysfunction. 3. The Veteran's status post left pyeloplasty with left flank pain and complex regional pain syndrome manifests as chronic left flank pain, occasional attack of colic, and an associated painful scar. 4. The Veteran's scar associated with a left pyeloplasty manifests as one painful linear scar measuring 18 cm. 5. In a December 1996 the RO denied service connection for a right traumatic cataract. The Veteran did not complete an appeal of that decision. 6. Evidence added to the record since the December 1996 decision denying service connection for a vision condition does not relate to an unestablished fact necessary to substantiate that claim or raise a reasonable possibility of substantiating that claim. 7. In a February 1997 decision, the RO denied service connection for chronic epistaxis, septal deviation with turbinate hypertrophy; the Veteran did not complete an appeal of that decision. 8. Evidence added to the record since the February 1997 decision denying service connection for chronic epistaxis, septal deviation with turbinate hypertrophy is not related to an unestablished fact necessary to substantiate that claim and does not raise a reasonable possibility of substantiating that claim. 9. In a May 1998 decision, the RO denied service connection for chronic low back pain and right knee chondromalacia patella; the Veteran did not complete an appeal of that decision. 10. Evidence added to the record since the May 1998 decision denying service connection for a lumbar spine disability relates to an unestablished fact necessary to substantiate that claim and raises a reasonable possibility of substantiating that claim. 11. Evidence added to the record since the May 1998 decision denying service connection for a right knee condition relates to an unestablished fact necessary to substantiate that claim and raises a reasonable possibility of substantiating that claim. 12. In an August 2002 decision, the RO denied service connection for a headache disability; the Veteran did not complete an appeal of that decision. 13. Evidence added to the record since the August 2002 decision denying service connection for a headache disability does not relate to an unestablished fact necessary to substantiate that claim or raise a reasonable possibility of substantiating that claim. 14. In an August 2002 decision, the RO denied service connection for depression; the Veteran did not complete an appeal of that decision. 15. Evidence added to the record since the August 2002 decision denying service connection for depression relates to unestablished facts necessary to substantiate that claim and raises a reasonable possibility of substantiating that claim. 16. The Veteran's cervical spine condition is not related to his active service or to a service connected disability. 17. The Veteran's degenerative joint disease of the right shoulder is not related to his active service or to a service connected disability. 18. The Veteran's degenerative joint disease of the left shoulder is not related to his active service or to a service connected disability. 19. The Veteran's widespread chronic pain, also claimed as myofascial pain syndrome, is not related to his active service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran on the issues of service connection for ulcers, chest condition, and erectile dysfunction have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria for a rating higher than 10 percent for status post left pyeloplasty with left flank pain and complex regional pain syndrome have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.115b, Diagnostic Code (DC) 7508 (2017). 3. The criteria for a rating higher than 10 percent for scar associated with a left pyeloplasty have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Code (DC) 7804 (2017). 4. The December 1996 RO decision that denied service connection for right traumatic cataract is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §20.1103 (2017). 5. The criteria for reopening a claim of entitlement to service connection for vision condition have not all been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. §3.156 (a) (2017). 6. The February 1997 RO decision that denied service connection for chronic epistaxis, septal deviation with turbinate hypertrophy is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §20.1103 (2017). 7. The criteria for reopening a claim of entitlement to service connection for chronic epistaxis, septal deviation with turbinate hypertrophy have not all been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. §3.156 (a) (2017). 8. The May 1998 RO decision that denied service connection for chronic low back pain and right knee chondromalacia patella is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §20.1103 (2017). 9. The criteria for reopening a claim of entitlement to service connection for chronic low back pain have all been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. §3.156 (a) (2017). 10. The criteria for reopening a claim of entitlement to service connection for right knee chondromalacia patella have all been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. §3.156 (a) (2017). 11. The August 2002 RO decision that denied service connection for a headache condition is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §20.1103 (2017). 12. The criteria for reopening a claim of entitlement to service connection for a headache condition have not all been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. §3.156 (a) (2017). 13. The August 2002 RO decision that denied service connection for depression is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §20.1103 (2017). 14. The criteria for reopening a claim of entitlement to service connection for depression have all been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. §3.156 (a) (2017). 15. The criteria for service connection for cervical spine condition have not all been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 16. The criteria for service connection for degenerative joint disease of the right shoulder have not all been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 17. The criteria for service connection for degenerative joint disease of the left shoulder have not all been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 18. The criteria for service connection for widespread chronic pain, also claimed as myofascial pain syndrome, have not all been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (2012). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2017). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the appellant has withdrawn his appeals on the issues of service connection for ulcers, chest condition, and erectile dysfunction and, hence, there remain no allegations of errors of fact or law for appellate consideration as to these issues. Accordingly, the Board does not have jurisdiction to review the appeal on the issues of service connection for ulcers, chest condition, and erectile dysfunction and they are dismissed. II. Due Process With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See generally, 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159, 3.326 (2017). III. Disability Ratings Generally Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). A. IR - Pyeloplasty The Veteran was original granted service connection for left status post pyeloplasty in a December 1996 rating decision. At that time this disability was rated noncompensable (0 percent) effective November 30, 1996. This was increased to 10 percent in the September 2010 rating decision on appeal. The Veteran's left status post pyeloplasty is currently rated under DC 7508 for nephrolithiasis. This diagnostic code instructs that nephrolithiasis should be rated as hydronephrosis (DC 7509) except for cases where there is recurrent stone formation requiring one or more of the following: drug therapy, diet therapy, and/or invasive or non-invasive procedures more than twice per year. 38 C.F.R. § 4.115b. In that case, a 30 percent rating is warranted. 38 C.F.R. § 4.115b, DC 7508. Under DC 7509, hydronephrosis where there is only an occasional attack of colic, not infected and not requiring catheter drainage warrants a 10 percent rating. 38 C.F.R. § 4.115b. A 20 percent rating is warranted when there are frequent attacks of colic, requiring catheter drainage. 38 C.F.R. § 4.115b, DC 7509. A maximum 30 percent evaluation is warranted when there are frequent attacks of colic with infection (pyonephrosis), with impaired kidney function. Id. If hydronephrosis is severe, it is rated as renal dysfunction. Id. Renal dysfunction is rated under 38 C.F.R. § 4.115a. Under this regulation, a 30 percent evaluation is warranted for albumin in the urine, whether constant or recurring, with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under DC 7101. Id. A 60 percent evaluation is warranted for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under DC 7101. Id. An 80 percent evaluation is warranted for persistent edema and albuminuria with BUN 40 to 80mg% or creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Id. A 100 percent evaluation is warranted for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems. Id. A March 2009 private treatment record notes that the Veteran reported kidney stones that were treated surgically five to ten years prior without follow up. He denied hematuria. He had no recent history of passing stones or gravel. He was voiding with good stream. He had no urinary incontinence. He had mild frequency of urination. In a June 2009 letter, the Veteran's private urologist noted that the Veteran had some mild urinary incontinence. He was not using pads, but needed to change his underwear occasionally. This had been going on for at least six months. This physician noted that the Veteran had some sort of spinal injury and they wanted to make sure that there was not an underlying problem. A July 2009 private treatment record notes that the Veteran had a history of spinal injury and complained of intermittent urinary incontinence. This record stated that although the Veteran had urinary incontinence it was not thought that his left renal hydronephrosis directly related to his neurological disorder. This record notes stress incontinence. In a July 2009 private treatment record the Veteran was noted to be unable to hold urine. Similarly, an August 2009 Social Security Administration (SSA) report of contact notes that he was incontinent and need to wear diapers. In a December 2009 letter, the Veteran reported incontinence requiring three or four pads a day and two to three diapers per night and kidney blockage with urinary difficulties. In December 2009 the Veteran underwent a VA examination in conjunction with this claim. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation. Thus it is adequate for VA purposes. At that time the Veteran reported recurrent urinary and stool incontinence that he thought was related to kidney stones. He claimed that he used three to four pads per day. He also reported two attacks of kidney stones in the prior year that were treated by private physicians, but the examiner did not have those records to review. There was a history of hospitalization and surgery in 1987 when the Veteran underwent pyeloplasty. There was no history of trauma to the genitourinary system and no history of neoplasm. There were no general systemic symptoms due to genitourinary disease. There were no urinary symptoms. The Veteran reported continual urine leakage requiring the Veteran to wear absorbent materials that had to be changed two to four times per day. There was no history of recurrent urinary tract infections or obstructed voiding. There was a history of urinary tract stones with two invasive and two non-invasive procedures in the prior 12 months. There was no history of renal dysfunction or failure. There was no history of acute nephritis. There was a history of hydronephrosis with two attacks of colic with infection in the prior 12 months, but no ureteral or kidney drainage was required. There were no cardiovascular symptoms. The Veteran had erectile dysfunction that was most likely due to neurologic disease. Physical examination found no abdominal or flank tenderness. His bladder and urethra were normal. There was normal perineal sensation. There was no peripheral edema. Dorsalis pedal pulses and posterior tibial pulses were normal bilaterally. Examination of his penis, testicles, epididymis, spermatic cord, scrotum, and seminal vesicles were normal. Laboratory tests showed creatinine at 1.2 and BUN at 18. The examiner noted that the Veteran was unemployed since 2009 when he retired due to myelopathy. She also stated that his urinary incontinence was secondary to his myelopathy. The Veteran's current kidney disability had mild effects on chores, exercise, sports, recreation, and traveling, but no effect on shopping, feeding, bathing, dressing, toileting, and grooming. This examiner found that this disability would prevent the Veteran from engaging in physical or sedentary employment during attacks, but would not prevent physical or sedentary employment when he was not having a kidney stone attack. In March 2011 the Veteran underwent a VA examination in conjunction with this claim. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation. Thus it is adequate for VA purposes. At that time the Veteran reported left flank pain and, temporarily, urinary incontinence. He stated that pain persisted and irradiated to his back and left leg. He had several hospitalizations for back and leg pain. There was no history of trauma to the genitourinary system and no history of neoplasm. There were no general systemic symptoms due to genitourinary disease. There were urinary symptoms of dysuria and dribbling, but not urgency, hesitancy/difficulty starting stream, straining to urinate, hematuria, urine retention, or urethral discharge. There was no urinary leakage and no history of recurrent urinary tract infections. There was a history of obstructed voiding but it did not cause recurrent urinary tract infections and did not require catheterization or dilations. There was a history of urinary tract stones; no special diet had been prescribed. No invasive or non-invasive procedures had been performed in the prior 12 months. There was no history of renal dysfunction or failure. There was no history of acute nephritis or hydronephrosis. There were no cardiovascular symptoms and no erectile dysfunction. Physical examination found percussion tenderness to the left flank and back. His bladder, urethra, anus, and rectum walls were normal. There was normal perineal sensation. There was no peripheral edema. Dorsalis pedal pulses and posterior tibial pulses were normal bilaterally. Examination of his penis, testicles, prostate, epididymis, spermatic cord, scrotum, and seminal vesicles were normal. His cremasteric reflex was normal. The examiner noted that the Veteran was unemployed since 2009 when he retired due to back, leg, and neck conditions. This disability had significant effects on his occupational functioning, causing decreased concentration, inappropriate behavior, decreased mobility, problems with lifting and carrying, difficulty reaching, lack of stamina, weakness or fatigue, decreased strength of the lower extremity, urinary incontinence, and pain. This resulted in increased absenteeism. The Veteran's current kidney disability had severe effects on chores, shopping, exercise, sports, recreation, traveling, bathing, and dressing, and moderate effect on feeding, toileting, and grooming. This examiner found that the Veteran' complex regional pain syndrome, described as back and flank pain, was caused by his status post left pyeloplasty despite lack of objective proof of residual renal condition. In June 2012 the Veteran underwent a VA examination in conjunction with this claim. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation. Thus it is adequate for VA purposes. At that time the Veteran reported sharp left flank pain that radiated to different areas of his body such as his legs and arms. The Veteran did not take continuous medication for this disability. He did not have renal dysfunction or urolithiasis (kidney, urethral, or bladder calculi). He did not have treatment for recurrent stone formation in the kidney, ureter, or bladder. He did not have a history of recurrent symptomatic urinary tract or kidney infections. He had not undergone kidney transplant or removal. The Veteran did not have a benign or malignant neoplasm or metastases related to this disability. He had one associated linear scar measuring 18 cm. that was painful. The Veteran described this as sharp shooting pain radiating to arms, legs, and other parts of the body. This scar was not unstable and did not cause limitation of function. This examiner found that the Veteran's kidney disability and scar would impair his ability to obtain and maintain physical and sedentary employment. His scar was painful and the pain increased with movement and radiated. Based on the above, the Veteran's left status post pyeloplasty with complex regional pain syndrome has been manifest chronic left flank and back pain, occasional attack of colic, and painful scar. This is consistent with the current 10 percent rating. See 38 C.F.R. § 4.115b, DC 7508-7509. As noted above, although its origin was questioned at the time, the December 2009 VA examiner attributed the Veteran's complaints of urinary incontinence in 2009 to myelopathy, not his kidney disability. As such, this symptom s not considered part of the Veteran's disability picture for his service connected left status post pyeloplasty with complex regional pain syndrome. A higher rating would require frequent attacks of colic that required catheter drainage or with infection or impaired kidney function, recurrent stone formation requiring drug therapy, diet therapy and/or invasive or non-invasive procedures more than twice per year, or severe hydronephrosis with renal dysfunction. See 38 C.F.R. § 4.115b, DC 7508, 7509. None of these symptoms are shown here. Hence the appeal as to a higher rating for this disability must be denied. Based on the above, the Board finds that the preponderance of the evidence is against a rating higher than 10 percent for left status post pyeloplasty with complex regional pain syndrome. Hence the appeal as to a higher rating for this disability must be denied. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. B. Scar Rating The Veteran's scar associated with a left pyeloplasty is currently rated under Diagnostic Code (DC) 7804 for a painful or unstable scar. Under this diagnostic code, one or two scars that are unstable or painful are rated 10 percent disabling. 38 C.F.R. § 4.118, DC 7804. Three or more scars that are unstable or painful are rated 20 percent disabling. Id. Five or more scars that are unstable or painful are 30 percent disabling. Id. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, DC 7804, Note (1). 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. 38 C.F.R. § 4.118, DC 7804, Note (2). Note (3) provides that scars evaluated under diagnostic codes 7800, 7891, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118. Based on the evidence detailed above, the Veteran has one painful linear scar associated with a left pyeloplasty and it measures 18 cm. This is consistent with the current 10 percent rating. See 38 C.F.R. § 4.118, DC 7804. A higher rating under this diagnostic code would require evidence of either two or more additional scars or instability. Neither is shown here. As such, a rating higher than 10 percent is not available under this diagnostic code. The Board has also considered whether a higher rating is available under another diagnostic code. This scar is not located on the Veteran's head, face, or neck, so a higher rating is not available under DC 7800. 38 C.F.R. § 4.118. There is no showing that this scar is deep or nonlinear or that it covers a total area greater than six square inches as required for a compensable rating under DC 7801. Id. Similarly, there is no evidence that this scar covers a total area greater than 144 square inches as required for a compensable rating under DC 7802. Id. Thus, a higher rating is not available for this scar under another diagnostic code. Based on the above, the Board finds that the preponderance of the evidence is against a rating higher than 10 percent for scar associated with a left pyeloplasty. Hence the appeal as to a higher rating for this disability must be denied. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. C. Extraschedular Considerations The Board finds that the Veteran's symptom of back and left flank pain as part of his of left status post pyeloplasty with complex regional pain syndrome is not expressly contemplated by the schedular rating criteria. As such, the Board must considered whether referral for an extraschedular rating under 38 C.F.R. § 3.321(b)(1) is warranted in this case. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Under Secretary for Benefits or the Director, Compensation Service, for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. 38 C.F.R. § 3.321(b). The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director, Compensation Service, for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. Here, the additional symptom of left flank and back pain attributed to the Veteran's complex regional pain syndrome is not show to have resulted in any hospitalization or additional marked interference with employment. As such, referral to the Under Secretary for Benefits or the Director, Compensation Service, is not necessary. IV. New and Material Evidence The Veteran was previously denied service connection for degenerative joint disease of the lumbar spine, vision condition, chronic epistaxis and septal deviation with turbinate hypertrophy (nasal condition), right knee chondromalacia, headaches, and depression and anxiety. Generally, a claim which has been denied in an unappealed AOJ decision is final and may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §20.1100 (2017). Once the AOJ makes a determination as to a claim, it must mail to the claimant, and his or her representative if there is one, proper notice of the decision, including notice of the claimant's procedural due process and appellate rights. 38 U.S.C. § 7105 (b)(1) (2012); 38 C.F.R. §§ 3.103 (b)(1), 19.25, 20.1103 (2017). The exception to this rule of not reviewing the merits of a finally denied claim is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. The regulation that implements 38 U.S.C. § 5108 defines "new and material evidence" as evidence not previously submitted to agency decision makers which is neither cumulative nor redundant of evidence previously of record, and which by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim, and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2017). New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). 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. Id. New and material evidence can be neither cumulative nor redundant of the evidence already of record and must raise a reasonable possibility of substantiating the claim. Id. Of note, under 38 C.F.R. § 3.156(b), "new and material" evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. If VA receives new evidence within the appeal period of an AOJ decision, it must make a determination as to whether the evidence is new and material and if it does not do so then the claim does not become final but rather it remains pending. See Beraud v. McDonald, 766 F.3d 1402, 1406-07 (Fed. Cir. 2014). In determining whether evidence is "new and material," the credibility of the evidence in question must be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). A. Vision Condition Prior to the filing of the current claim of entitlement to service connection for vision condition, the AOJ previously denied a claim of service connection for right traumatic cataract in December 1996. Generally, a claim which has been denied in an unappealed AOJ decision is final and may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §20.1100 (2017). Once the AOJ makes a determination as to a claim, it must mail to the claimant, and his or her representative if there is one, proper notice of the decision, including notice of the claimant's procedural due process and appellate rights. 38 U.S.C. § 7105 (b)(1) (2012); 38 C.F.R. §§ 3.103 (b)(1), 19.25, 20.1103 (2017). An appeal of an AOJ decision to the Board is initiated by the filing of a notice of disagreement (NOD) with the decision. 38 U.S.C. § 7105 (a) (2012); 38 C.F.R. § 20.200 (1996). An NOD is a statement, reduced to writing, which can reasonably be construed as expressing dissatisfaction with the AOJ's decision and a desire to contest the result. 38 U.S.C. § 7105 (b); 38 C.F.R. § 20.201 (1996). Except in the case of simultaneously contested claims (which this is not) the NOD must be filed within one year from the date of mailing of result of the initial determination. See 38 U.S.C. § 7105 (b)(1); see also 38 C.F.R. §§ 20.200, 20.201, 20.302 (1996). If a timely NOD is not filed, the determination becomes final and the claim will not thereafter be reopened or allowed, except as may otherwise be provided by regulations not inconsistent with Title 38 of the U.S. Code. 38 U.S.C. § 7105 (c) (2012). Here, the Veteran did not appeal the December 1996 rating decision and it became final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §20.1103 (2017). The December 1996 rating decision denied service connection, finding that right traumatic cataract existed prior to service and there was no objective evidence of worsening during the Veteran's active duty service. The question becomes whether any evidence received since the December 1996 relates to an unestablished fact necessary to substantiate a claim of entitlement to service connection for a vision condition. The evidence received since the December 1996 includes additional VA, private, and Social Security Administration (SSA record) and the Veteran's lay statements and testimony. Of these, only the Veteran's lay testimony suggests that his pre-existing traumatic right cataract underwent any worsening in service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, knowledge of the natural progression of pre-existing traumatic right cataract is required. Therefore, the Veteran is not competent to provide lay evidence of in-service aggravation of this pre-existing disability. As such, the evidence received since the December 1996 rating decision does not relate to an unestablished fact necessary to substantiate a claim of entitlement to service connection for a vision condition and the claim is not reopened. B. Nasal Disability The Veteran was previously denied service connection for chronic epistaxis, septal deviation with turbinate hypertrophy in a February 1997 rating decision. Again, once the AOJ makes a determination as to a claim, it must mail to the claimant, and his or her representative if there is one, proper notice of the decision, including notice of the claimant's procedural due process and appellate rights. 38 U.S.C. § 7105 (b)(1) (2012); 38 C.F.R. §§ 3.103 (b)(1), 19.25, 20.1103 (2017). An appeal of an AOJ decision to the Board is initiated by the filing of a notice of disagreement (NOD) with the decision. 38 U.S.C. § 7105 (a) (2012); 38 C.F.R. § 20.200 (1997). An NOD is a statement, reduced to writing, which can reasonably be construed as expressing dissatisfaction with the AOJ's decision and a desire to contest the result. 38 U.S.C. § 7105 (b); 38 C.F.R. § 20.201 (1997). Except in the case of simultaneously contested claims (which this is not) the NOD must be filed within one year from the date of mailing of result of the initial determination. See 38 U.S.C. § 7105 (b)(1); see also 38 C.F.R. §§ 20.200, 20.201, 20.302 (1997). If a timely NOD is not filed, the determination becomes final and the claim will not thereafter be reopened or allowed, except as may otherwise be provided by regulations not inconsistent with Title 38 of the U.S. Code. 38 U.S.C. § 7105 (c) (2012). Here, the Veteran did not file a timely notice of disagreement and the February 1997 rating decision became final. See 38 U.S.C. § 7105 (c); 38 C.F.R. § 20.1103. The February 1997 rating decision denied service connection, finding that the Veteran was not treated for sinusitis or rhinitis in service. There was no underlying etiology for this condition which existed prior to service. He was also noted to have a deviated septum but there was no evidence of trauma in service. His nosebleeds were related to deviated septum and turbinate hypertrophy that existed prior to service. The evidence received since the February 1997 rating decision includes additional VA, private, and Social Security Administration (SSA record) and the Veteran's lay statements and testimony. In his July 2009 claim, the Veteran claimed that his nosebleeds were secondary to his other claimed condition. To date, the Veteran has not provided any medical evidence to support this theory of entitlement. In his September 2016 hearing testimony, the Veteran stated that he had nosebleeds before service and underwent nasal surgery during and after service. This is consistent with the evidence of record at the time of the earlier rating decision, which including the Veteran's reported medical history in an August 1996 service treatment record wherein he reported septorhinoplasty in 1989. As such, this evidence is not new. Thus, the evidence received since the February 1997 rating decision does not relate to an unestablished fact necessary to substantiate a claim of entitlement to service connection for a nasal disability and the claim is not reopened. C. Lumbar Spine The Veteran was previously denied service connection for chronic low back pain in a May 1998 rating decision. Again, once the AOJ makes a determination as to a claim, it must mail to the claimant, and his or her representative if there is one, proper notice of the decision, including notice of the claimant's procedural due process and appellate rights. 38 U.S.C. § 7105 (b)(1) (2012); 38 C.F.R. §§ 3.103 (b)(1), 19.25, 20.1103 (2017). An appeal of an AOJ decision to the Board is initiated by the filing of a notice of disagreement (NOD) with the decision. 38 U.S.C. § 7105 (a) (2012); 38 C.F.R. § 20.200 (1999). An NOD is a statement, reduced to writing, which can reasonably be construed as expressing dissatisfaction with the AOJ's decision and a desire to contest the result. 38 U.S.C. § 7105 (b); 38 C.F.R. § 20.201 (1999). Except in the case of simultaneously contested claims (which this is not) the NOD must be filed within one year from the date of mailing of result of the initial determination. See 38 U.S.C. § 7105 (b)(1); see also 38 C.F.R. §§ 20.200, 20.201, 20.302 (1999). If a timely NOD is not filed, the determination becomes final and the claim will not thereafter be reopened or allowed, except as may otherwise be provided by regulations not inconsistent with Title 38 of the U.S. Code. 38 U.S.C. § 7105 (c) (2012). If the claimant files a timely NOD and the disagreement is not resolved, the AOJ must provide the claimant and his or her representative, if there is one, with an SOC. 38 U.S.C. § 7105 (d) (2012); 38 C.F.R. § 19.30 (2017). As a general rule, the appellant must file a substantive appeal within 60 days of the mailing of the SOC or within one year of the notice of the decision being appealed, whichever is later. 38 U.S.C. § 7105 (d)(1); 38 C.F.R. § 20.302 (b) (2017). A substantive appeal consists of a properly completed VA Form 9 or a correspondence containing the necessary information. 38 C.F.R. § 20.200 (1999). If a claimant fails to respond after receipt of the SOC, the AOJ may close the case. 38 U.S.C. § 7105 (d)(3); 38 C.F.R. § 19.32 (2012). Once the AOJ closes the case for failure to complete the appeal to the Board, the AOJ decision is final. 38 U.S.C. § 7105 (c); 38 C.F.R. § 20.1103. Here, the Veteran filed a notice of disagreement in February 1999. The RO issued a statement of the case in March 1999. The Veteran did not perfect his appeal with a timely substantive appeal and the May 1998 rating decision became final. See 38 U.S.C. § 7105 (c); 38 C.F.R. § 20.1103. The May 1998 rating decision denied service connection finding that there was no evidence of chronic low back pain during military service and no evidence showing that this condition was related to the Veteran's let knee disability. The Veteran's previous attempt to reopen this claim was denied in a January 2001 rating decision. In March 2001 he filed a notice of disagreement with that denial. The RO did not issue a statement of the case in response to that rating decision but did issue a March 2015 statement of the case. The evidence received since the May 1998 rating decision includes a July 2015 opinion that found that the Veteran's back pain was most likely caused by his chronic knee problems. As a current medical nexus opinion was lacking at the time of the May 1998 rating decision, which was the last decision on the merits, this new evidence relates to an unestablished fact necessary to substantiating the claim. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Accordingly, the Board concludes that the criteria for reopening a claim of service connection for a lumbar spine disability have been met. D. Right Knee The Veteran was previously denied service connection for right knee chondromalacia patella in a May 1998 rating decision. Again, once the AOJ makes a determination as to a claim, it must mail to the claimant, and his or her representative if there is one, proper notice of the decision, including notice of the claimant's procedural due process and appellate rights. 38 U.S.C. § 7105 (b)(1) (2012); 38 C.F.R. §§ 3.103 (b)(1), 19.25, 20.1103 (2017). An appeal of an AOJ decision to the Board is initiated by the filing of a notice of disagreement (NOD) with the decision. 38 U.S.C. § 7105 (a) (2012); 38 C.F.R. § 20.200 (1999). An NOD is a statement, reduced to writing, which can reasonably be construed as expressing dissatisfaction with the AOJ's decision and a desire to contest the result. 38 U.S.C. § 7105 (b); 38 C.F.R. § 20.201 (1999). Except in the case of simultaneously contested claims (which this is not) the NOD must be filed within one year from the date of mailing of result of the initial determination. See 38 U.S.C. § 7105 (b)(1); see also 38 C.F.R. §§ 20.200, 20.201, 20.302 (1999). If a timely NOD is not filed, the determination becomes final and the claim will not thereafter be reopened or allowed, except as may otherwise be provided by regulations not inconsistent with Title 38 of the U.S. Code. 38 U.S.C. § 7105 (c) (2012). If the claimant files a timely NOD and the disagreement is not resolved, the AOJ must provide the claimant and his or her representative, if there is one, with an SOC. 38 U.S.C. § 7105 (d) (2012); 38 C.F.R. § 19.30 (2017). As a general rule, the appellant must file a substantive appeal within 60 days of the mailing of the SOC or within one year of the notice of the decision being appealed, whichever is later. 38 U.S.C. § 7105 (d)(1); 38 C.F.R. § 20.302 (b) (2017). A substantive appeal consists of a properly completed VA Form 9 or a correspondence containing the necessary information. 38 C.F.R. § 20.200 (1999). If a claimant fails to respond after receipt of the SOC, the AOJ may close the case. 38 U.S.C. § 7105 (d)(3); 38 C.F.R. § 19.32 (2012). Once the AOJ closes the case for failure to complete the appeal to the Board, the AOJ decision is final. 38 U.S.C. § 7105 (c); 38 C.F.R. § 20.1103. Here, the Veteran filed a notice of disagreement in February 1999. The RO issued a statement of the case in March 1999. The Veteran did not perfect his appeal with a timely substantive appeal and the May 1998 rating decision became final. See 38 U.S.C. § 7105 (c); 38 C.F.R. § 20.1103. The May 1998 rating decision denied service connection finding that there was no evidence of right knee chondromalacia patella during military service and no evidence showing that this condition was related to the Veteran's left knee disability. The evidence received since the May 1998 rating decision includes a November 2014 VA treatment record that noted that the Veteran's left knee surgery in 1994 resulted in him depending on his right knee more, which led to increased right knee pain. As evidence suggesting a link between the Veteran's right knee condition and his service connected left knee condition was lacking at the time of the May 1998 rating decision, which was the last decision on the merits, this new evidence relates to an unestablished fact necessary to substantiating the claim. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Accordingly, the Board concludes that the criteria for reopening a claim of service connection for a right knee disability have been met. E. Headaches The Veteran was previously denied service connection for Persian Gulf Illness (to include fatigue, skin, headache, muscle and joint pain, neurologic signs, signs involving upper and lower respiratory, sleep disturbance, gastrointestinal signs, and hair loss) in an August 2002 rating decision. Once the AOJ makes a determination as to a claim, it must mail to the claimant, and his or her representative if there is one, proper notice of the decision, including notice of the claimant's procedural due process and appellate rights. 38 U.S.C. § 7105 (b)(1) (2012); 38 C.F.R. §§ 3.103 (b)(1), 19.25, 20.1103 (2017). An appeal of an AOJ decision to the Board is initiated by the filing of a notice of disagreement (NOD) with the decision. 38 U.S.C. § 7105 (a) (2012); 38 C.F.R. § 20.200 (2002). An NOD is a statement, reduced to writing, which can reasonably be construed as expressing dissatisfaction with the AOJ's decision and a desire to contest the result. 38 U.S.C. § 7105 (b); 38 C.F.R. § 20.201 (2002). Except in the case of simultaneously contested claims (which this is not) the NOD must be filed within one year from the date of mailing of result of the initial determination. See 38 U.S.C. § 7105 (b)(1); see also 38 C.F.R. §§ 20.200, 20.201, 20.302 (2002). If a timely NOD is not filed, the determination becomes final and the claim will not thereafter be reopened or allowed, except as may otherwise be provided by regulations not inconsistent with Title 38 of the U.S. Code. 38 U.S.C. § 7105 (c) (2012). Here, the Veteran did not file a timely notice of disagreement and the August 2002 rating decision became final. See 38 U.S.C. § 7105 (c); 38 C.F.R. § 20.1103. The August 2002 rating decision denied service connection finding that there was no evidence of an undiagnosed illness. There was a record of treatment for headache following a fall wherein the Veteran hit his head in November 1999, after his separation from service, and those headaches were secondary to muscle strain after the fall. Additionally, there was no evidence of Gulf War service. Evidence received since the August 2002 rating decision includes private treatment and Social Security Administration (SSA) records that note complaints of chronic headaches following a work-related motor vehicle accident in January 2008. There is no additional evidence suggesting that the Veteran has a headache condition related to his active duty military service. As such, the evidence received since the August 2002 rating decision does not relate to an unestablished fact necessary to substantiate a claim of entitlement to service connection for a headache condition and the claim is not reopened. F. Depression The Veteran was previously denied service connection for major depression in an August 2002 rating decision. Once the AOJ makes a determination as to a claim, it must mail to the claimant, and his or her representative if there is one, proper notice of the decision, including notice of the claimant's procedural due process and appellate rights. 38 U.S.C. § 7105 (b)(1) (2012); 38 C.F.R. §§ 3.103 (b)(1), 19.25, 20.1103 (2017). An appeal of an AOJ decision to the Board is initiated by the filing of a notice of disagreement (NOD) with the decision. 38 U.S.C. § 7105 (a) (2012); 38 C.F.R. § 20.200 (2002). An NOD is a statement, reduced to writing, which can reasonably be construed as expressing dissatisfaction with the AOJ's decision and a desire to contest the result. 38 U.S.C. § 7105 (b); 38 C.F.R. § 20.201 (2002). Except in the case of simultaneously contested claims (which this is not) the NOD must be filed within one year from the date of mailing of result of the initial determination. See 38 U.S.C. § 7105 (b)(1); see also 38 C.F.R. §§ 20.200, 20.201, 20.302 (2002). If a timely NOD is not filed, the determination becomes final and the claim will not thereafter be reopened or allowed, except as may otherwise be provided by regulations not inconsistent with Title 38 of the U.S. Code. 38 U.S.C. § 7105 (c) (2012). Here, the Veteran did not file a timely notice of disagreement and the August 2002 rating decision became final. See 38 U.S.C. § 7105 (c); 38 C.F.R. § 20.1103. The August 2002 rating decision denied service connection finding that there was no evidence of this condition during active duty and no current evidence of major depression secondary to service connected disabilities. The evidence received since the August 2002 rating decision includes an October 2013 VA treatment record that diagnosed the Veteran with a mood disorder due to general medical condition, bereavement, and anxiety disorder. As this suggests both a current psychiatric condition and the possibility that it may be linked to his current service connected disabilities (as they are part of his general medical condition), it relates to unestablished facts necessary to substantiating the claim. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Accordingly, the Board concludes that the criteria for reopening a claim of service connection for depression have been met. V. Service Connection Generally Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, including hypertension and arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2017). A. Cervical Spine and Bilateral Shoulders The Veteran is seeking service connection for a cervical spine condition and degenerative joint disease of the bilateral shoulders. With regard to the question of presumptive service connection for the Veteran's degenerative disc disease of the cervical spine, the Board finds that this condition did not manifest to a compensable degree within the one-year presumptive period. A compensable (10 percent) degree of arthritis requires establishment of arthritis by x-ray findings and limitation of motion objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. 4.71a, Diagnostic Code 5003. In this case, a July 2009 MRI of the cervical spine found mild degenerative disc disease. The record does not show x-ray evidence of cervical spine arthritis within one year of the Veteran's separation from service. As such, service connection on a presumptive basis is not warranted. See 38 C.F.R. § 3.307 (a)(3). Thus, the Board will now address whether service connection on a direct basis is warranted. The Veteran has a current diagnosis of cervical arthritis and has provided lay evidence of bilateral shoulder pain. No opinion has been provided for these issues. VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). Here, the Board finds no indication that a neck or shoulder disease or injury occurred in service. At his September 2016 hearing, the Veteran testified that he injured his neck, back, and both shoulders in the same weight-lifting injury as he injured his left knee. He stated that the knee injury was an emergency necessitating that he be medevacked and so that was the focus of his treatment despite his contemporaneous back and neck complaints. He described this injury as falling with the weights. This is inconsistent with his service treatment records which do not reflect a known trauma to his left knee or show that he was immediately medevacked following a weight-lifting injury. Instead, the May 1994 service treatment record notes that the Veteran awoke on May 4, 1994 with swelling of the knee. He had no known trauma, but had a history of doing weight-lifting squats. Given that his history of weight-lifting squats was noted as was his knee injury, if he had neck or shoulder symptoms or injury at that time it is highly likely that it would have been recorded. As such, the Board finds the Veteran's report of weight-lifting injuries to his neck and both shoulders to be not credible. Absent an in-service an event, injury, or disease to which the Veteran's current neck and/or shoulder complaints can be linked, as required for direct service connection, an opinion on the question of direct service connection is not necessary. The Board notes that records following the Veteran's January 2008 post-service work-related motor vehicle accident attribute neck and shoulder pain to that accident. As that accident did not occur during service, it cannot form the basis for a grant of service connection. For the reasons stated above, the Board finds that the preponderance of evidence is against the Veteran's claims of entitlement to service connection for cervical spine condition and degenerative joint disease of the bilateral shoulders and his appeals on those issues must be denied. There is no reasonable doubt to be resolved as to these issues. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Widespread Chronic Pain The Veteran is also seeking service connection widespread chronic pain. The Veteran has linked this condition to service in the Persian Gulf. He has participated in VA Gulf War illness research studies and sought treatment through the VA Gulf War Illness Clinic. There is no indication that the Veteran's participation in these activities was predicated on a conclusive finding that he was a Persian Gulf veteran within the definition of 38 C.F.R. § 3.317. Upon review of the file, the Board does not find evidence establishing that the Veteran is a Persian Gulf veteran. The Veteran's period of service overlaps the Persian Gulf War, but he has not been shown to have service in the Southwest Asia theater of operations during this time. As such, he is not shown to be a Persian Gulf veteran within the definition of 38 C.F.R. § 3.317 and is not entitled to service connection for undiagnosed or medically unexplained chronic illness under this regulation. Thus, the Board will address whether service connection on a direct basis is warranted. The Veteran has provided lay evidence of widespread chronic pain. No opinion has been provided for this issue. Again, VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon, 20 Vet. App. 79, 81-82. Here, the Board finds no indication that a disease or injury related characterized by widespread chronic pain occurred in service. At his September 2016 hearing, the Veteran testified that his widespread chronic pain was related to anthrax shots in service and stated that Dr. N.K., a VA Gulf War illness doctor, had attributed these symptoms to Gulf War illness or anthrax shots. As noted above, the Veteran is not shown to have the requisite service in the Southwest Asia theater of operations to qualify as a Persian Gulf veteran. Additionally, a review of the service treatment immunization records show immunizations for influenza, polio, adenovirus, meningococcal disease, rubella, and bicillin, but does include any indication that the Veteran received anthrax shots in service. Absent an in-service an event, injury, or disease to which the Veteran's current widespread chronic pain can be linked, as required for direct service connection, an opinion on the question of direct service connection is not necessary. For the reasons stated above, the Board finds that the preponderance of evidence is against the Veteran's claim of entitlement to service connection for widespread chronic pain and his appeal must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. ORDER The appeal on the issue of service connection for ulcers is dismissed. The appeal on the issue of service connection for chest condition is dismissed. The appeal on the issue of service connection for erectile dysfunction is dismissed. A rating in excess of 10 percent disabling for status post left pyeloplasty with left flank pain and complex regional pain syndrome is denied. A rating in excess of 10 percent disabling for a scar associated with a left pyeloplasty is denied. New and material evidence having not been received; the claim of entitlement to service connection for a bilateral vision condition, previously denied as a traumatic cataract condition is not reopened. New and material evidence having not been received; the claim of entitlement to service connection for chronic epistaxis and septal deviation with turbinate hypertrophy is not reopened. New and material evidence has been received; the claim of entitlement to service connection for a lumbar spine disability is reopened. New and material evidence has been received; the claim of entitlement to service connection for chondromalacia of the right knee is reopened. New and material evidence having not been received; the claim of entitlement to service connection for a headache disability is not reopened. New and material evidence has been received; the claim of entitlement to service connection for depression is reopened. Service connection for a cervical spine condition is denied. Service connection for degenerative joint disease of the right shoulder is denied. Service connection for degenerative joint disease of the left shoulder is denied. Service connection for widespread chronic pain, also claimed as myofascial pain syndrome is denied. REMAND The Veteran underwent a June 2015 VA examination in conjunction with his claim for an increased rating for left knee disability. At that time, the examiner stated that he was unable to offer an opinion as to whether pain, weakness, fatigability, or incoordination significantly limited the Veteran's functional ability during a flare-up without resorting to speculation since "I would need to resort to speculation in this hypothetical situation." In Sharp v. Shulkin, 29 Vet. App. 26 (2017) the Court clarified the responsibilities of a VA examiner and the Board when an examiner is asked to provide an opinion as to additional functional loss during flare-ups of a musculoskeletal disability, pursuant to DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court found that an examiner's finding that he or she could not offer an opinion without resorting to speculation in this instance could be adequate if: (1) the record is clear that the examiner has "considered all procurable and assembled data" before stating that an opinion cannot be reached; and (2) the examiner explains the basis for his or her conclusion that a non-speculative opinion cannot be offered, see Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). If an examiner cannot offer an opinion without resorting to speculation and explains his or her inability within the Jones criteria, the Board must determine whether the examiner's inability results from a personal lack of knowledge or experience and, if so, seek an opinion from a more qualified examiner. See Sharp at 36. In this case, the provided rationale is inadequate to relieve the examiner from providing such an opinion as it appear to be related to the examiner's general aversion to offering an opinion on issues not directly observed. Thus a new examination and opinion are necessary on remand. With regard to his lumbar spine disability claim that was reopened above, the June 2015 opinion, the VA examiner found that the Veteran's right knee condition was less likely than not proximately due to or the result of his service connected left knee disability, noting that the Veteran's left knee disability caused him to do less activity that he otherwise would have to place less stress on the left knee. This reduced activity level also results in the Veteran placing less stress on his right knee than he otherwise would. This opinion appears to be based only on the Veteran's current level of inactivity and does not account for the two decades that elapsed between the Veteran's left knee surgery and this examination, during which the Veteran was shown to have a higher level of activity including employment as a corrections officer. As such, on remand, the VA knee examiner is asked to provide an opinion on the question of secondary service connection. With regard to his lumbar spine disability claim that was reopened above, the July 2015 private opinion that found that the Veteran's back pain was most likely caused by his chronic knee problems. As such, a relationship between his service connected left knee disability and his lumbar spine disability is suggested and VA's duty to provide an examination is triggered. The claim for entitlement to service connection for left leg pain is intertwined with the Veteran's pending claim of service connection for a lumbar spine disability as there is some indication that the claimed left leg pain may be related to the Veteran's back. Thus a decision on that claim may impact the adjudication of the left leg pain claim. Issues "inextricably intertwined" with an issue certified for appeal are to be identified and developed prior to appellate review. Harris v. Derwinski, 1 Vet. App. 180 (1991). Therefore, this claim must be remanded to the AOJ in accordance with the holding in Harris to allow the AOJ to fully develop and adjudicate it. The Veteran is seeking service connection for hypertension. In his lay statements he has associated this with his service connected and claimed conditions. The Board notes that the rating criteria for his service connected status post left pyeloplasty with left flank pain and complex regional pain syndrome includes, at a more severe level, contemplation of hypertension. As such, a relationship between this service connected disability and hypertension is suggested and VA's duty to provide an examination is triggered. The Veteran is also seeking service connection for weakness in the bilateral upper and lower extremities. The record notes the Veteran's complaints of weakness in the bilateral upper and lower extremities. His July 1996 physical examination board examination notes left quadriceps weakness with atrophy. As the Veteran had documented extremity weakness in service and has current extremity weakness, VA's duty to provide an examination is triggered. As noted above, the Veteran's claim of service connection for depression has been reopen. The Veteran's recent acquired psychiatric diagnoses have included major depressive disorder, depression, and anxiety. As there is significant overlap in the Veteran's reported symptoms, the Board has combined the reopened depression claim with the claim for an acquired psychiatric claim other than depression as a claim of service connection for an acquired psychiatric condition. The Veteran underwent a March 2011 VA examination in conjunction with his acquired psychiatric condition claim. At that time, the examiner stated that she was unable to provide an opinion without speculation because the medical workups were inconclusive about etiology of the Veteran's pain. While this is true, the Veteran has been granted service connection for status post left pyeloplasty with left flank pain and complex regional pain syndrome, a painful associated scar, and a left knee disability. As these disabilities are associated with pain, the examiner's rationale for failing to provide an opinion is inadequate. On remand, VA should seek a new examination to determine whether the Veteran's current acquired psychiatric disability is causally linked to the pain associated with one or more of his service connected disabilities. The claim for entitlement to a TDIU is intertwined with the Veteran's pending increased rating and service connection claims, as decisions on those claims may impact the adjudication of the TDIU claim. Again, issues "inextricably intertwined" with an issue certified for appeal are to be identified and developed prior to appellate review. Harris, 1 Vet. App. 180. Therefore, this claim must be remanded to the AOJ in accordance with the holding in Harris to allow the AOJ to fully develop and adjudicate it. Accordingly, the case is REMANDED for the following action: 1. Ensure that the Veteran is scheduled for a VA knee examination by an examiner who has not previously examined him for the purpose of ascertaining his current level of disability. The claims file must be reviewed by the examiner and the examiner must note whether the claims file was reviewed. a. The examiner must describe the nature and severity of all manifestations of the Veteran's left knee disability. In this regard, the examiner should record the range of motion observed on clinical evaluation, in terms of degrees of extension and forward flexion for both knees. In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree of flexion and/or extension at which such pain begins. The extent of any weakened movement, excess fatigability, and incoordination on use should also be described by the examiner. In order to comply with regulations, as explained in Correia v. McDonald, 28 Vet. App. 158 (2016), the examiner must test and record the range of motion for the lumbar spine in active motion, passive motion, weight-bearing, and nonweight-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 assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. The examiner is reminded that he or she should specify the degree of additional functional loss/motion due to pain, to include during flare-ups, or state why it was not feasible to provide such information, as required for an adequate examination. If the examiner cannot provide an opinion as to additional functional impairment during flare-ups, he or she must comment on whether an opinion could not be rendered because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. See Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). The agency of original jurisdiction should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained. If no such opinion can be provided due to a personal lack of knowledge or experience on the part of the examiner, the agency of original jurisdiction should seek the opinion of a more qualified examiner. c. Provide a medical opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current right knee disability was caused or chronically worsened beyond its natural progression by his service connected left knee disability. If the examiner cannot provide the above opinion, the examiner is advised that he/she should explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed, such as additional records and/or diagnostic studies. If the examiner cannot provide the answer because further information is needed to assist in making the determination, all reasonable steps to obtain this missing information should be exhausted before concluding that the answer cannot be provided. 2. Ensure that the Veteran is scheduled for a VA spine examination. The claims file must be reviewed by the examiner and the examiner must note whether the claims file was reviewed. All indicated studies should be conducted, and all findings reported in detail. The examiner must accomplish the following and must include a rationale to support all opinions provided. Provide a medical opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current lumbar spine disability was caused or has been chronically worsened beyond its natural progression (aggravated) by his service-connected left knee disability and/or the right knee disability that is also on remand. If the examiner cannot provide the above opinion, the examiner is advised that he/she should explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed, such as additional records and/or diagnostic studies. If the examiner cannot provide the answer because further information is needed to assist in making the determination, all reasonable steps to obtain this missing information should be exhausted before concluding that the answer cannot be provided. 3. Ensure that the Veteran is scheduled for a VA hypertension examination. The claims file must be reviewed by the examiner and the examiner must note whether the claims file was reviewed. All indicated studies should be conducted, and all findings reported in detail. The examiner must accomplish the following and must include a rationale to support all opinions provided. Provide a medical opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current hypertension was caused or has been chronically worsened beyond its natural progression (aggravated) by his service connected status post left pyeloplasty with left flank pain and complex regional pain syndrome. If the examiner finds that his hypertension has been chronically worsened beyond its natural progression by his service-connected status post left pyeloplasty with left flank pain and complex regional pain syndrome, then the examiner must indicate, to the extent possible, the approximate level of disability (i.e., a baseline) before the onset of such worsening. If the examiner cannot provide any of the above opinions, the examiner is advised that he/she should explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed, such as additional records and/or diagnostic studies. If the examiner cannot provide the answer because further information is needed to assist in making the determination, all reasonable steps to obtain this missing information should be exhausted before concluding that the answer cannot be provided. 4. Ensure that the Veteran is scheduled for a VA neurologic examination by an examiner. The claims file must be reviewed by the examiner and the examiner must note whether the claims file was reviewed. All indicated studies should be conducted, and all findings reported in detail. The examiner must accomplish the following and must include a rationale to support all opinions provided. a. Identify any and all conditions that account for the Veteran's reported symptoms of weakness in the bilateral upper and lower extremities. b. For each condition identified, provide a medical opinion as to whether it is at least as likely as not (50 percent probability or greater) that this condition had onset during active service or was caused by active service. In doing so, the examiner is asked to specifically address the notation of left quadriceps weakness with atrophy in the Veteran's July 1996 physical examination board examination report. If the examiner cannot provide any of the above opinions, the examiner is advised that he/she should explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed, such as additional records and/or diagnostic studies. If the examiner cannot provide the answer because further information is needed to assist in making the determination, all reasonable steps to obtain this missing information should be exhausted before concluding that the answer cannot be provided. 5. Ensure that the Veteran is scheduled for a VA psychiatric examination by an examiner who has not previously examined him. The claims file must be reviewed by the examiner and the examiner must note whether the claims file was reviewed. All indicated studies should be conducted, and all findings reported in detail. The examiner must accomplish the following and must include a rationale to support all opinions provided. Provide a medical opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current acquired psychiatric disability was caused or has been chronically worsened (aggravated) by his service connected disabilities, including pain associated with status post left pyeloplasty with left flank pain and complex regional pain syndrome, associated scar, and left knee disability. If the examiner finds that his hypertension has been chronically worsened beyond its natural progression by his service-connected status post left pyeloplasty with left flank pain and complex regional pain syndrome, then the examiner must indicate, to the extent possible, the approximate level of disability (i.e., a baseline) before the onset of such worsening. If the examiner cannot provide any of the above opinions, the examiner is advised that he/she should explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed, such as additional records and/or diagnostic studies. If the examiner cannot provide the answer because further information is needed to assist in making the determination, all reasonable steps to obtain this missing information should be exhausted before concluding that the answer cannot be provided. 6. Thereafter, readjudicate the claims of an increased rating for left knee disability; service connection for lumbar spine disability, left leg pain, hypertension, weakness in bilateral upper and lower extremities, an acquired psychiatric disorder, and right knee disability; and TDIU. If any of the benefits sought are not granted, furnish to the Veteran and his representative a supplemental statement of the case and allow an appropriate opportunity to respond before returning the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs