Citation Nr: 18161212 Decision Date: 12/31/18 Archive Date: 12/31/18 DOCKET NO. 16-24 726A DATE: December 31, 2018 ORDER Entitlement to service connection for tinnitus is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a sleep condition is denied. Entitlement to service connection for migraine headaches is denied. Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder, anxiety disorder, depression, and posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection for a heart condition is denied. Entitlement to an effective date prior to September 2, 2014 for the award of service connection for limitation of extension of the left knee is denied. Entitlement to an effective date prior to September 2, 2014 for the award of service connection for internal derangement of the left knee is denied. Entitlement to an effective date prior to September 2, 2014 for the award of service connection for a right knee strain is denied. Entitlement to an initial rating in excess of 10 percent for internal derangement of the left knee is denied. Entitlement to an initial 10 percent, but no higher, rating for limitation of extension of the left knee is granted throughout the appeal period, subject to the regulations governing the payment of monetary awards. Entitlement to an initial rating in excess of 10 percent for a right knee strain is denied. Entitlement to a separate 10 percent, but no higher, rating for painful limitation of extension of the right knee is granted throughout the appeal period, subject to the regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for cataracts with senile nuclear sclerosis and diabetic macular edema (bilateral eye condition) is remanded. Entitlement to a kidney condition is remanded. FINDINGS OF FACT 1. The preponderance of the evidence weighs against a finding that the Veteran’s current tinnitus is attributable to the Veteran’s active service or any incident of service. 2. The preponderance of the evidence weighs against a finding that the Veteran’s hypertension is attributable to the Veteran’s active service or any incident of service. 3. The Veteran does not have a sleep condition disability. 4. The preponderance of the evidence weighs against a finding that the Veteran’s migraine headaches are attributable to the Veteran’s active service or any incident of service. 5. The preponderance of the evidence is against a finding that the Veteran’s acquired psychiatric disorder is attributable to the Veteran’s active service or any incident of service. 6. The preponderance of the evidence weighs against a finding that the Veteran’s heart condition is attributable to the Veteran’s active service or any incident of service. 7. VA received an informal claim of entitlement to service connection for bilateral knee conditions on June 8, 2012; however, VA received the Veteran’s VA Form 21-526 on September 2, 2014. 8. Throughout the appeal period, the Veteran’s internal derangement of the left knee has been manifested by flexion at most limited to 75 degrees with pain. 9. Throughout the appeal period, the Veteran’s left knee has been manifested by extension at most limited to 5 degrees with pain. 10. Throughout the appeal period, the Veteran’s right knee strain has been manifested by flexion at most limited to 100 degrees with pain. 11. Throughout the appeal period, the Veteran’s right knee has been manifested by full extension with pain.   CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 2. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 3. The criteria for service connection for a sleep condition are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for migraine headaches are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 5. The criteria for service connection for an acquired psychiatric disorder are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for a heart condition are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 7. The criteria for an effective date prior to September 2, 2014 for the award of service connection for internal derangement of the left knee are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.155, 3.400. 8. The criteria for an effective date prior to September 2, 2014 for the award of service connection for limitation of extension of the left knee are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.155, 3.400. 9. The criteria for an effective date prior to September 2, 2014 for the award of service connection for a right knee strain are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.155, 3.400. 10. The criteria for an initial rating in excess of 10 percent for internal derangement of the left knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5257, 5258, 5259, 5260. 11. The criteria for an initial 10 percent, but no higher, rating for painful limitation of extension of the left knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5261. 12. The criteria for an initial rating in excess of 10 percent for a right knee strain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5257, 5258, 5259, 5260. 13. Throughout the appeal period, the criteria for a separate 10 percent, but no higher, rating for painful limitation of extension of the right knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.45, 4.7, 4.71a, Diagnostic Code 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from May 1976 to July 1976. These matters are before the Board of Veterans’ Appeals (Board) on appeal from January 2016 and April 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The United States Court of Appeals for Veterans Claims (Court) has held that, although a Veteran claims service connection for a specified diagnosed disability, it cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any disability that may reasonably be encompassed by several factors, including the Veteran’s description of the claim, the symptoms the Veteran describes, and the information the Veteran submits or that VA obtains in support of the claim. The Court reasoned that a Veteran does not file a claim to receive benefits only for a particular diagnosis, but for the affliction (symptoms) his condition, however described, causes him. Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). Here, although the Veteran filed his claim seeking service connection for “mental condition” specifically, the record reflects diagnoses of adjustment disorder, anxiety disorder, depression, and PTSD. The Board therefore finds that, pursuant to Clemons, the Veteran’s claim seeking service connection for a mental condition is more accurately characterized as one for any acquired psychiatric disorder and has recharacterized the issue accordingly. 23 Vet. App. at 5-6. The Veteran was awarded service connection for left knee instability and assigned a 20 percent disability rating in a June 2016 rating decision. Following the Veteran’s timely notice of disagreement with the decision, the RO issued a statement of the case in December 2017 that denied an earlier effective date of the grant of service connection and denied a rating in excess of 20 percent. The Veteran did not appeal the December 2017 statement of the case. The time period for appeal has elapsed. As such, the issue is not before the Board, and the Board will not address whether the Veteran is entitled to a rating in excess of 20 percent for left knee instability. Service Connection Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Certain chronic diseases (e.g., tinnitus and migraine headaches as organic diseases of the nervous system, hypertension, and coronary artery disease and congestive heart failure) may be presumptively service connected if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307, 3.309. If a condition listed as a chronic disease in § 3.309(a) is noted during service, but is either shown not to be chronic or the diagnosis could be legitimately questioned, then a showing of continuity of related symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331(Fed. Cir. 2013). 1. Entitlement to service connection for tinnitus is denied. The Veteran generally contends his current tinnitus disability is related to service. 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 tinnitus began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). With regards to whether the Veteran’s tinnitus is related to an in-service injury, event, or disease, the Veteran’s service personnel records illustrate the Veteran’s military occupational specialty was that of a track vehicle technician. Such a military occupational specialty has a high probability of noise exposure. Therefore, the Veteran meets the first two requirements of service connection, so the remaining issue is whether the Veteran’s tinnitus is related to his in-service noise exposure. Following an October 2015 VA examination, the examiner opined that the Veteran’s tinnitus is less likely than not caused by or the result of military noise exposure. In support of the opinion, the examiner cited to how the Veteran did not report a significant history of protracted noise exposure during his short duration of military service. The examiner noted how the Veteran reported a long history of industrial noise exposure after service as an automobile detail finisher. Further, the examiner noted how the Veteran reported that his tinnitus began around age 49 or 50, which is many years after the Veteran’s service. The Veteran is competent as a layperson to report what he has experienced personally through his senses. See Layno v. Brown, 6 Vet. App. 465 (1994). However, a detailed review of the record illustrates there are no reports of tinnitus other than at the October 2015 VA examination. The Veteran’s report that his tinnitus began around age 49 or 50 is approximately 20 years after the Veteran’s service. The Board gives great probative weight to the October 2015 VA examiner’s opinion that the Veteran’s current tinnitus is not related to in-service noise exposure. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. In reaching the above conclusion, the Board distinguishes this matter from Buchanan v. Nicholson, 451 F.3d 1331 (2006), wherein the Federal Circuit determined that the Board had erred by finding that a claimant’s report of in-service symptoms lacked credibility solely because there was no objective medical evidence corroborating those symptoms at the time. Indeed, here, the Board is not relying merely upon a general absence of complaints in the service records; rather, the Board is relying on the service personnel records, along with the post-service medical evidence that does not reflect evidence of tinnitus until 2015. The Board has also considered whether the Veteran’s tinnitus is considered chronic pursuant to 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a), and he is therefore, entitled to service connection under the presumptive theory of entitlement. However, the Veteran served on active duty for less than 90 days, and 90 days of continuous service is required for application of the chronic disease presumptions. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Thus, the Board will not further discuss this theory of entitlement. Moreover, continuity of symptomatology is not established, and he is not entitled to service connection under the provisions of § 3.303(b). 38 C.F.R. § 3.303(b); Walker, 708 F.3d 1331. As is noted above, the Veteran was first diagnosed with tinnitus in 2015, and the Veteran did not report having tinnitus until around age 49 or 50, so approximately in 1999 or 2000. The report of tinnitus is over two decades after service and the first diagnosis is over three decades after separation of service. Further, the Veteran received no treatment for his tinnitus prior to the October 2015 VA examination. In summary, the preponderance of the evidence is against a finding that the Veteran’s current tinnitus disability is related to service. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim for service connection, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App., 49, 53-56 (1990). 2. Entitlement to service connection for hypertension is denied. The Veteran generally contends his current hypertension disability is related to service. The Board concludes that, while the Veteran has hypertension, which is a chronic disease under the appropriate regulations, it did not manifest in service and continuity of symptomatology is not established. 38 U.S.C. § 1131; Walker, 708 F.3d 1331; 38 C.F.R. §§ 3.303(b), 3.309(a). Regarding presumptive service connection for hypertension as a chronic disease, as noted above, the Veteran served on active duty for less than 90 days and does not have qualifying service for application of the chronic disease presumptions. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Thus, the Board will not further discuss this theory of entitlement. A review of the Veteran’s service treatment records does not reveal any complaints, findings, treatment, or diagnoses relating to hypertension. The Veteran’s blood pressure at his January 1976 Army National Guard enlistment examination was 127/89. A review of the record illustrates that VA treatment records show that the Veteran has had diagnoses of hypertension since April 2009. Although the evidence does not specifically show when hypertension was initially diagnosed, the Veteran has not indicated that he has had a continuity of symptomatology of hypertension since his discharge from service and there is no evidence indicating such. The first indication of record that the Veteran had hypertension is in the April 2009 medical record. Accordingly, a preponderance of the evidence is against a theory of service connection based on continuity of symptomatology. 38 C.F.R. §§ 3.303(b), 3.309(a). While the Veteran is competent to report having experienced symptoms of hypertension, he is not competent to provide a diagnosis in this case or determine that any such symptoms were manifestations of hypertension. The issue is medically complex, as it requires the interpretation of diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran has not been afforded an examination in connection with his hypertension claim, but VA does not have a duty to provide one here. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (VA’s duty to provide an examination only triggered if the evidence of record “indicates” that the claimed disability or symptoms “may be” associated with the established event). There is clear evidence in the file that the Veteran has hypertension, but there is nothing to indicate that hypertension was incurred in service or that there is an association between his hypertension and his service. Accordingly, there is no duty to provide the Veteran with an examination to evaluate the etiology of his hypertension. Without any evidence in support of the Veteran’s claim, the Board finds that no medical nexus exists between the Veteran’s hypertension and an in-service injury, event or disease. 38 U.S.C. § 1131; Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). In summary, the preponderance of the evidence is against a finding that the Veteran’s current hypertension disability is related to service. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim for service connection, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Gilbert, 1 Vet. App., at 53-56.   3. Entitlement to service connection for a sleep condition is denied. The Veteran generally contends he has a sleep condition that is related to service. The question for the Board 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. The Board concludes that the Veteran does not have a current diagnosis of a sleep condition and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1131, 5107(b); Holton, 557 F.3d at 1366; Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). A review of the record illustrates there is no diagnosis of a sleep condition. The Board acknowledges that the Veteran has reported difficulties with sleep at multiple VA medical appointments beginning in 2009. However, no physician provided a diagnosis of any sleep condition. The existence of a current disability is the cornerstone of a claim for service connection and VA disability compensation. 38 U.S.C. § 1131; Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Here, the Veteran has not had a sleep condition disability at any point during the appeal period. Additionally, there is no indication that his symptom of having difficulty sleeping has caused him any functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Therefore, the Board cannot grant his claim under any theory of entitlement. While the Veteran’s application for service connection for a sleep condition illustrates the Veteran believes he has a current sleep condition disability for VA purposes, he is not competent to provide a diagnosis in this case. The issue is medically complex as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377. The Veteran has not been afforded an examination in connection with his sleep condition claim, but VA does not have a duty to provide one here. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (VA’s duty to provide an examination only triggered if the evidence of record “indicates” that the claimed disability or symptoms “may be” associated with the established event). Although there is evidence the Veteran experiences difficulty sleeping, which would be sufficient to meet the first prong of McLendon, there is nothing to indicate incurrence in service or an association with service. Accordingly, there is no duty to provide the Veteran with an examination to evaluate the etiology of any sleep difficulties. The Board does not question the Veteran’s sincerity in his belief that service connection is warranted for a sleep condition. However, without evidence of a current sleep condition disability, a preponderance of the evidence is against the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Gilbert, 1 Vet. App., at 53-56. As such, service connection for a sleep condition is denied. 4. Entitlement to service connection for migraine headaches is denied. The Veteran generally contends his current migraine headaches are related to service. The questions for the Board are whether the Veteran’s current migraine headaches are related to service, and whether continuity of symptomatology has existed since service. The Board concludes that, while the Veteran has a current diagnosis of hemiplegic migraine, the preponderance of the evidence weighs against finding that the Veteran’s migraine headaches began during service or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1131, 5107(b); Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). With regards to whether the Veteran’s migraine headaches are related to an in-service injury, event, or disease, a review of the Veteran’s service treatment records illustrates there are no reports of headaches during service. The Board has also considered whether the Veteran’s headaches are considered chronic pursuant to 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a). VA policy considers migraine headaches to be an organic disease of the nervous system, but headaches alone, are not. Therefore, the Veteran’s headaches, diagnosed in July 2009 as hemiplegic migraines are considered a “chronic disease” listed under 38 C.F.R. § 3.309(a). However, the Veteran served on active duty for less than 90 days and, as a result, the chronic disease presumptions do not apply. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Thus, the Board will not further discuss this theory of entitlement. Although the evidence does not specifically show when the migraines were initially diagnosed, the Veteran has not indicated that he experienced a continuity of symptomatology of headaches since his discharge from service and there is no evidence indicating such continuity. The first indication of record that the Veteran had migraines is in the July 2009 medical record. Accordingly, a preponderance of the evidence is against the theory of service connection for migraine headaches based on continuity of symptomatology. 38 C.F.R. §§ 3.303(b), 3.309(a). The Veteran has not been afforded an examination in connection with his migraine headaches claim, but VA does not have a duty to provide one here as there is no indication that his migraine headaches may be associated with his service. See McLendon, 20 Vet. App. at 83 (VA’s duty to provide an examination only triggered if the evidence of record “indicates” that the claimed disability or symptoms “may be” associated with the established event). There is clear evidence in the file that the Veteran has had a migraine headache, but there is nothing to indicate that there is an association between his migraine headaches and his service. Accordingly, there is no duty to provide the Veteran with an examination to evaluate the etiology of his migraine headaches. Without any evidence in support of the Veteran’s claim, the Board finds that no medical nexus exists between the Veteran’s migraine headaches and an in-service injury, event or disease. 38 U.S.C. § 1131; Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). In summary, the preponderance of the evidence is against a finding that the Veteran’s current migraine headaches are related to service. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim for service connection, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Gilbert, 1 Vet. App., at 53-56. 5. Entitlement to service connection for an acquired psychiatric disorder is denied. The Veteran generally contends his current acquired psychiatric disorder is related to service. The question for the Board 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. The Board concludes that, while the Veteran has current diagnoses of adjustment disorder, anxiety disorder, depression, and PTSD, the preponderance of the evidence is against finding that the Veteran’s acquired psychiatric disorder began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1131, 5107(b); Holton, 557 F.3d at 1366; 38 C.F.R. §§ 3.303(a), (d), 3.304. The record does not reflect and the Veteran has not asserted that his acquired psychiatric disorder is related to any specific event while in service, including a specific stressor event, given the indication of a diagnosis of PTSD, or to service in general. A review of the Veteran’s service treatment records does not reveal any complaints, findings, treatment, or diagnoses relating to an acquired psychiatric disorder. A review of the record illustrates that VA treatment records show that the Veteran has had diagnoses of psychiatric disorders since September 2009. While the Veteran is competent to report having experienced symptoms of an acquired psychiatric disorder and when they began, he has not specified when his psychiatric symptoms began, and in any event, he is not competent to provide a diagnosis in this case or determine that any such symptoms were manifestations of an acquired psychiatric disorder. The issue is medically complex, as it requires the interpretation of diagnostic medical testing. Jandreau, 492 F.3d at 1377. The Veteran has not been afforded an examination in connection with this claim, but VA does not have a duty to provide one here. See McLendon, 20 Vet. App. at 83 (VA’s duty to provide an examination only triggered if the evidence of record “indicates” that the claimed disability or symptoms “may be” associated with the established event). There is clear evidence in the file that the Veteran has an acquired psychiatric disorder, but there is nothing to indicate that such was incurred in service or that there is an association between his acquired psychiatric disorder and his service. Accordingly, there is no duty to provide the Veteran with an examination to evaluate the etiology of his acquired psychiatric disorder. Without any evidence in support of the Veteran’s claim, the Board finds that no medical nexus exists between the Veteran’s acquired psychiatric disorder and an in-service injury, event or disease. 38 U.S.C. § 1131; Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). In summary, the preponderance of the evidence is against a finding that the Veteran’s current acquired psychiatric disorder was incurred in or is related to service. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim for service connection, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Gilbert, 1 Vet. App., at 53-56. 6. Entitlement to service connection a heart condition is denied. The Veteran generally contends his current heart condition is related to service. The Board concludes that, while the Veteran has diagnoses of congestive heart failure and coronary artery disease, which are chronic diseases under the appropriate regulations, his heart condition was not incurred in or related to his service and continuity of symptomatology is not established. 38 U.S.C. § 1131; Walker, 708 F.3d 1331; 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Regarding presumptive service connection for congestive heart failure and coronary artery disease as a chronic disease, as previously noted, the Veteran served on active duty for less than 90 days and does not have qualifying service for application of the chronic disease presumptions. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Thus, the Board will not further discuss this theory of entitlement. A review of the Veteran’s service treatment records does not reveal any complaints, findings, treatment, or diagnoses relating to a heart condition. A review of the record illustrates that VA treatment records show that the Veteran was diagnosed with congestive heart failure in April 2009 and was diagnosed with coronary artery disease beginning in June 2011. Although the evidence does not specifically show when a chronic heart condition under the regulations was initially diagnosed, the Veteran has not indicated that symptoms of a heart condition have been continuous since his discharge from service and there is no evidence indicating such. The first indication of record that the Veteran had a heart condition is in the April 2009 medical record. Accordingly, a preponderance of the evidence is against the theory of service connection for a heart condition based on a continuity of symptomatology. 38 C.F.R. §§ 3.303(b), 3.309(a). The Veteran has not been afforded an examination in connection with his heart condition claim, but VA does not have a duty to provide one here. See McLendon, 20 Vet. App. at 83 (VA’s duty to provide an examination only triggered if the evidence of record “indicates” that the claimed disability or symptoms “may be” associated with the established event). There is clear evidence in the file that the Veteran has a heart condition, but there is nothing to indicate that it was incurred in service or that there is an association between his heart condition and his service. Accordingly, there is no duty to provide the Veteran with an examination to evaluate the etiology of his heart condition. While the Veteran is competent to report having experienced symptoms of a heart condition, he is not competent to provide a diagnosis or etiology in this case. These issues are medically complex, as they require the interpretation of diagnostic medical testing and knowledge of complex bodily systems. Jandreau, 492 F.3d at 1377. Without any evidence in support of the Veteran’s claim, the Board finds that no medical nexus exists between the Veteran’s heart condition and an in-service injury, event or disease. 38 U.S.C. § 1131; Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). In summary, the preponderance of the evidence is against a finding that the Veteran’s current heart condition disability is related to service. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim for service connection, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Gilbert, 1 Vet. App., at 53-56. Earlier Effective Date Claims Unless specifically provided otherwise in the statute, the effective date of an award based on an original claim for compensation or for a reopened claim for benefits shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Regulations defining a “claim” were revised, effective March 24, 2015. See 79 Fed. Reg. 57,660 (Sept. 25, 2014). The revision eliminated informal claims and required claims on specific forms. In this case, however, the applicable regulations are those prior to the revision, as this claim was pending prior to March 24, 2015. As such, the Board will apply the regulations effective prior to March 24, 2015 regarding defining a claim. A specific claim in the form prescribed by the Secretary is necessary for disability benefits to be paid to any individual under the laws administered by VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151. For VA compensation purposes, a “claim” is defined as a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1(p). An informal claim is any communication or action indicating an intent to apply for one or more benefits, and identifying the benefit sought from a claimant, his or her authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris. See 38 C.F.R. § 3.155(a). Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year after the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(b). Thus, the essential elements for any claim, whether formal or informal, are (1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). VA must look to all communications from a claimant that may be interpreted as an application or claim for benefits and is required to identify and act on informal claims for benefits. See Servello v. Derwinski, 3 Vet. App. 196, 198 (1992).   Entitlement to an effective date prior to September 2, 2014, for the award of service connection for limitation of extension of the left knee, for the award of service connection for internal derangement of the left knee, and for the award of service connection for a right knee strain, is denied The Veteran has made no specific assertions as to why he is entitled to an effective date prior to his application date of September 2, 2014 for his bilateral knee conditions. The Board acknowledges a June 8, 2012 report of contact where the Veteran called VA to file claims of entitlement to service connection for bilateral knee conditions. Following the June 2012 telephone call, VA sent a letter and VA Form 21-526, Veteran’s Application for Compensation and Pension, to the Veteran at his current address informing the Veteran that he needed to submit the completed application within one year of receipt of the letter. Further, VA informed the Veteran that if he submitted a completed application within one year of receipt of the letter that VA would use June 8, 2012 as the application date. There is no indication that the Veteran did not receive the June 2012 letter. Thus, VA complied with the procedures set out in 38 C.F.R. § 3.155(b). There is no correspondence until September 2, 2014, the date VA received the Veteran’s application for disability benefits, following the June 2012 letter informing the Veteran of his rights. Therefore, VA received the Veteran’s application for service connection for bilateral knee conditions more than two years after the June 2012 informal claim. Thus, the date of the June 2012 informal claim cannot be used as the date of entitlement per 38 C.F.R. § 3.155(b) since the VA Form 21-526 was received after the one-year requirement. The Board notes that the exact date on which entitlement arose need not be ascertained in order to conclude that the September 2, 2014 date selected by the RO is the earliest possible effective date here with regards to the claims of service connection for the bilateral knee conditions. If entitlement arose prior to September 2, 2014, then the date of claim would be the later of the two, and hence the correct effective date as provided by 38 C.F.R. § 3.400(b)(2). Moreover, while VA must interpret a claimant’s submissions broadly, VA is not required to conjure up issues not raised by a claimant. In sum, the Board finds that the legally correct date of the grant of service connection for limitation of extension of the left knee, internal derangement of the left knee, and a right knee strain is September 2, 2014, the date VA received the Veteran’s VA Form 21-526 seeking entitlement to service connection for bilateral knee conditions. Therefore, the Veteran is not entitled to an earlier effective date and the claims must be denied. Bilateral Knee Increased Rating Claims The Veteran generally contends he is entitled to increased ratings for his bilateral knee disabilities. The RO has assigned a noncompensable rating for the Veteran’s limitation of extension of the left knee under Diagnostic Code 5261. The RO has rated the Veteran’s internal derangement of the left knee as 10 percent disabling under Diagnostic Code 5260 and the Veteran’s right knee strain as 10 percent disabling under Diagnostic Code 5260. As noted in the introductory material, the Veteran did not file a timely substantive appeal on the matter seeking an increased rating for a separate 20 percent rating for instability of the left knee. As such, that rating will not be discussed further. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). A Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Under Diagnostic Code 5260, a 10 percent rating is warranted where flexion is limited to 45 degrees, a 20 percent rating is available where flexion is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. Id. Under Diagnostic Code 5261, a 10 percent rating is warranted where extension of the knee is limited to 10 degrees, a 20 percent rating is warranted where extension is limited to 15 degrees, a 30 percent rating is warranted where extension is limited to 20 degrees, a 40 percent rating is warranted where extension is limited to 30 degrees, and a 50 percent rating is warranted where extension is limited to 45 degrees. Id. Normal ranges of motion of the knee are to 0 degrees in extension, and 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Separate ratings under Diagnostic Code 5260 and Diagnostic Code 5261 may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (Sept. 17, 2004). The Veteran may also be assigned separate ratings for limitation of motion under Diagnostic Codes 5260 or 5261 and for instability under Diagnostic Code 5257. See VAOPGCPREC 23-97 (July 1, 1997). Under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability, a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability, and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a separate 20 percent rating may be assigned for cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under Diagnostic Code 5259, a separate 10 percent rating may be assigned for the removal of cartilage, semilunar, that is symptomatic. Id. Degenerative and/or traumatic arthritis as shown by X-ray studies are rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In Petitti v. McDonald, 27 Vet. App. 415 (2015), the United States Court of Appeals for Veterans Claims (Court) rejected VA’s argument that § 4.59 requires painful motion, such that the mere presence of joint pain is not sufficient. Id. at 428-29. The Court held that under § 4.59, “the trigger for a minimum disability rating is an actually painful, unstable, or malaligned joint,” explaining that § 4.59 speaks to both painful motion of joints and actually painful joints. Id. at 425. Moreover, the Court held that § 4.59 does not require “objective” evidence, but can be satisfied with lay and other non-medical evidence. Id. at 429. Consideration of other Diagnostic Codes for rating a knee disability (5256, 5259, 5262, 5263) is inappropriate in this case as the Veteran’s bilateral knee disabilities do not include the pathology required in the criteria for those Diagnostic Codes (ankylosis, semilunar cartilage removal, malunion or nonunion of tibia or fibula, or genu recurvatum). 38 C.F.R. § 4.71a. Here, the Board will discuss the evidence as it relates to the Veteran’s knee disabilities prior to addressing the Veteran’s claims for increased ratings for his bilateral knee disabilities. The only relevant evidence that relates to the Veteran’s knee disabilities is a December 2015 VA examination. At the examination, the Veteran had reduced flexion in the left knee to 80 degrees with pain and reduced extension to 5 degrees with pain. On the right side, the Veteran had reduced flexion to 110 degrees with pain and full extension with pain. The Veteran was able to perform repetitive use testing without additional loss of range of motion. However, the examiner noted the Veteran had pain that significantly limited his functional ability with repeated use over time in the form of reduced flexion to 75 degrees in the left knee and reduced flexion to 100 degrees in the right knee. In addition, the examiner noted that pain upon flare-ups limited the Veteran’s functional ability in the form of reduced flexion to 75 degrees in the left knee and reduced flexion to 100 degrees in the right knee. The Veteran had additional contributing factors of disability bilaterally in the form of less movement than normal and pain on movement that caused instability of station, disturbances of locomotion, and interference with sitting and standing. The examiner reported the functional impact of the Veteran’s bilateral knee disabilities is that they cause limitations with prolonged standing, walking, running, squatting, and jumping. The examiner noted the Veteran had no joint instability in the right knee but he had 1+ lateral instability in the left knee. The Veteran had no recurrent subluxation bilaterally, no recurrent effusion bilaterally, no recurrent patellar subluxation or dislocation bilaterally, no ankylosis bilaterally, and no meniscal conditions bilaterally. The Veteran reported at the examination that his knee conditions began in service and the conditions have progressed since service. He reported flare-ups in the form of locking and swelling bilaterally that occur once every two weeks and last three to four days. In addition, the Veteran reported he has used a cane on the right side for at least 10 years. Turning to the ratings assigned by the RO. The RO has assigned a noncompensable rating for the Veteran’s limitation of extension of the left knee under Diagnostic Code 5261 and a 10 percent rating for the Veteran’s internal derangement of the left knee under Diagnostic Code 5260. For the right knee, the RO has assigned a 10 percent rating for the Veteran’s knee strain under Diagnostic Code 5260. Following a review of the evidence addressed above, for the left knee, the Board concludes that the evidence most nearly approximates the currently assigned 10 percent rating for the Veteran’s internal derangement of the left knee rated under Diagnostic Code 5260 for limitation of flexion. The Veteran has had no point throughout the appeal period where his flexion in his left knee has been less than 45 degrees, even when considering additional factors of pain, fatigue, and weakness. Although the December 2015 VA examiner indicated the Veteran experienced additional loss of flexion during flare ups and on repetitive use, such additional loss was noted to be to 75 degrees and noted to be 5 degrees less than prior to such testing. As such, even when considering these additional contributing factors, the evidence does not more nearly approximate flexion limited to less than 45 degrees. Therefore, a preponderance of the evidence is against a rating in excess of 10 percent based on limitation of flexion at any point during the appeal period. 38 C.F.R. § 4.71a, Diagnostic Code 5260. As to the Veteran’s limitation of extension rated under Diagnostic Code 5261 and currently assigned a noncompensable rating, the Board finds the evidence most nearly approximates a 10 percent rating based on painful left knee joint on extension throughout the appeal period. The December 2015 VA examination reflects the Veteran had objective evidence of pain with extension and pain upon repetitive use, with limitation of motion to 5 degrees. As such, the Board concludes that a 10 percent, but no higher, rating for an actually painful left knee joint with limitation of extension pursuant to 38 C.F.R. § 4.59 is warranted throughout the appeal period. A rating in excess of 10 percent under Diagnostic Code 5261 is not warranted as there is no evidence in the record that illustrates the Veteran has extension limited beyond 10 degrees. Regarding the Veteran’s right knee strain, currently assigned a 10 percent rating by the RO, the Board concludes that the evidence most nearly approximates the currently assigned 10 percent rating under Diagnostic Code 5260 for limitation of flexion. The Veteran has had no point throughout the appeal period where his flexion in his right knee has been less than 45 degrees, even when considering additional factors of pain, fatigue, and weakness. Although the December 2015 VA examiner indicated the Veteran experienced additional loss of flexion during flare ups and on repetitive use, such additional loss was noted to be to 100 degrees and noted to be 10 degrees less than prior to such testing. As such, even when considering these additional contributing factors, the evidence does not more nearly approximate flexion limited to less than 45 degrees. Therefore, a preponderance of the evidence is against a rating in excess of 10 percent based on limitation of flexion at any point during the appeal period. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Board has considered whether the Veteran is entitled to a separate compensable rating for limitation of extension of the right knee. The Board finds that the evidence more nearly approximates an actually painful right knee joint on extension throughout the appeal period, as reflected by the December 2015 VA examination which indicates the Veteran had objective evidence of pain with extension on the right side and pain upon repetitive motion bilaterally, with full extension. As such, the Board concludes that a separate 10 percent rating for an actually painful right knee joint with extension pursuant to 38 C.F.R. § 4.59 is warranted throughout the appeal period. A rating in excess of 10 percent under Diagnostic Code 5261 is not warranted as there is no evidence in the record that illustrates the Veteran has extension limited beyond 10 degrees. The Board acknowledges that the first objective evidence of painful right knee joint extension is at the December 2015 VA examination. However, giving the Veteran the benefit of the doubt, the Board has assigned the 10 percent rating under Diagnostic Code 5261 as of the date of the Veteran’s claim based on the subjective reports at the December 2015 VA examination and since the RO initially assigned the bilateral knee ratings as of the date of the application. See 38 U.S.C. § 5107(b). In evaluating the Veteran’s increased rating claims for his bilateral knees, the Board must address the provisions of 38 C.F.R. §§ 4.40 and 4.45. The Board recognizes the Veteran’s statements that his knee conditions cause locking and swelling and that he has to use a cane. However, even when considering the reported functional loss, the Veteran’s disability picture has not more nearly approximate flexion limited to 30 degrees, extension limited to 15 degrees, or ankylosis bilaterally. The Board has considered whether the Veteran is entitled to separate ratings under Diagnostic Codes 5257-5259. As is noted above, the Veteran has already been assigned a 20 percent rating for left knee instability under Diagnostic Code 5257. Furthermore, as is also noted above, the Veteran has not appealed the rating, so that issue is not before the Board. In regard to right knee instability, the December 2015 VA examiner noted the Veteran had no instability. The Court recently held that Diagnostic Code 5257 does not require objective evidence of instability. English v. Wilkie, No. 17-2083, 2018 U.S. App. Vet. Claims LEXIS 1464 (Vet. App. Nov. 1, 2018). The Board acknowledges the Veteran is competent to report experiencing such symptoms of giving way of the knee. However, the Veteran has not reported experiencing such symptoms at any time during the appeal period, including at the December 2015 VA examination. Therefore, the Board finds that a preponderance of the evidence is against a finding that the Veteran is entitled to a separate rating for recurrent subluxation or lateral instability in the right knee. The Board has considered whether the Veteran is entitled to a separate rating under Diagnostic Code 5258 for a bilateral semilunar cartilage condition since the Veteran reported bilateral locking at the December 2015 VA examination. However, the examiner noted the Veteran does not and has never had a semilunar condition in either knee. Additionally, there is no evidence of effusion into the joint or pain that is separate from the pain that is already being compensated under Diagnostic Codes 5260 and 5261. Therefore, the evidence does not more nearly approximate the criteria for a separate rating for either knee under Diagnostic Code 5258. The Board has considered whether the Veteran is entitled to a separate rating under Diagnostic Code 5259 for symptomatic removal of semilunar cartilage; however, there is no indication in the record that the Veteran has had surgery on either knee. Thus, a separate rating for either knee under Diagnostic Code 5259 is not supported by the record. Regarding whether referral for an extraschedular rating is appropriate, such has not been raised by the claimant or reasonably raised by the record and will not be further discussed herein. Doucette v. Shulkin, 28 Vet. App. 366, 369−70 (2017). In sum, the Board finds the criteria for a rating in excess of 10 percent for the Veteran’s left knee disability based on limitation of flexion have not been met during the pendency of the appeal. The Board finds that the Veteran is entitled to a 10 percent, but no higher, rating for painful limitation of extension of the left knee throughout the appeal period. The Veteran is not entitled to any separate ratings for the left knee. With regard to the right knee, the Board finds the criteria for a rating in excess of 10 percent for the Veteran’s right knee strain based on limitation of flexion have not been met during the pendency of the appeal. The Board finds that the Veteran is entitled to a separate 10 percent, but no higher, rating for painful limitation of extension of the right knee throughout the appeal period. The Veteran is not entitled to any further separate ratings for the right knee. REASONS FOR REMAND 1. Entitlement to service connection for diabetes mellitus and entitlement to service connection for a bilateral eye condition is remanded. A September 2018 signed form from the Veteran to release the Veteran’s “most recent diabetic eye exam” from VA to the private medical facility illustrates the Veteran may be receiving treatment at the private facility for his diabetes mellitus and diabetes related bilateral eye condition. A remand of these claims is required to allow VA to obtain authorization and request these records. 2. Entitlement to service connection for a kidney condition is remanded. VA treatment records in November 2015 and December 2015 reflect diagnoses of chronic kidney disease due to diabetes mellitus and hypertension. Thus, the issue of entitlement to service connection for a kidney condition is inextricably intertwined with the Veteran’s claim for service connection for diabetes mellitus. Therefore, the claim is also being remanded to the agency of original jurisdiction.   The matters are REMANDED for the following actions: Contact the Veteran and afford him the opportunity to identify or submit any pertinent evidence in support of his claim, to include records of any private treatment at Khair Family Practice. Based on his response, attempt to procure copies of all records which have not been obtained from identified treatment sources. Obtain and associate with the Veteran’s electronic record VA records from April 2017 to the present. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). M. Sorisio Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Breitbach, Associate Counsel