Citation Nr: 20008396 Decision Date: 01/31/20 Archive Date: 01/31/20 DOCKET NO. 19-16 472 DATE: January 31, 2020 ORDER New and material evidence has been received to reopen the claim of entitlement to service connection for a left foot disability. Entitlement to service connection for a left arm disability is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a neck/upper back disability is denied. Entitlement to a rating in excess of 10 percent for tinnitus is denied. Entitlement to a rating in excess of 10 percent for bilateral hearing loss is denied. Entitlement to an effective date earlier than April 13, 2016 for the award of service connection for right hip degenerative joint disease with limitation of extension is denied. Entitlement to an effective date earlier than April 13, 2016 for the award of service connection for right hip impairment of the thigh is denied. REMANDED Entitlement to an initial compensable rating for right hip degenerative arthritis impairment of the thigh is remanded. Entitlement to an initial rating in excess of 10 percent for right hip degenerative arthritis with limitation of extension is remanded. Entitlement to a a rating in excess of 20 percent for left ankle degenerative joint disease is remanded. Entitlement to a rating in excess of 10 percent for right hip degenerative arthritis with limitation of flexion is remanded. Entitlement to a rating in excess of 10 percent for left knee chondromalacia and degenerative joint disease is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for a left foot disability is remanded. Entitlement to a total disability rating due to service-connected disabilities based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. An unappealed November 2013 rating decision denied service connection for a left foot disability. 2. Evidence received more than one year since the November 2013 rating decision denying service connection for a left foot disability, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim of service connection for a left foot disability, and raises a reasonable possibility of substantiating the claim. 3. There is no competent evidence of a left arm disability or functional impairment of the left arm during the appeal period. 4. The Veteran’s right shoulder disability was not incurred in or as a result of service. 5. The Veteran’s neck/upper back disability was not incurred in or as a result of service. 6. The Veteran is receiving the maximum schedular rating for tinnitus. 7. Throughout the appeal period, the Veteran had, at worst Level I hearing acuity in the right ear and Level 1 hearing acuity in the left ear. 8. On April 13, 2016, VA received the Veteran’s intent to file a claim for compensation benefits. 9. On April 28, 2016, the Veteran submitted a properly completed VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, seeking right hip compensation benefits. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the claim of service connection for a left foot disability. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. The criteria for service connection for a left arm disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a neck/upper back disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for a rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.87, Diagnostic Code 6260. 6. The criteria for a rating in excess of 10 percent for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 7. The criteria for an effective date prior to April 13, 2016, for the award of service connection for right hip degenerative joint disease with limitation of extension have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.155, 3.400. 8. The criteria for an effective date prior to April 13, 2016, for the award of service connection for right hip impairment of the thigh have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.155, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1979 to March 1988. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a November 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In June 2019, the Veteran reasonably raised a claim for TDIU, and this issue is part of the instant appeal pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). Service Connection 1. Whether new and material evidence has been received to reopen service connection for a left foot disability. Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105. However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 C.F.R. § 5108. “New” evidence means existing evidence not previously submitted to agency decisionmakers. “Material” evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is “new and material,” the credibility of the new evidence must be presumed. Justus v. Principi, 3 Vet. App. 510 (1992). The provisions of 38 U.S.C. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead one should ask whether the evidence could reasonably substantiate the claim to be reopened, either by triggering VA’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Historically, an unappealed November 2013 rating decision denied the Veteran’s claim of service connection for a left foot disability. No additional evidence pertinent to this issue was associated with the claims file within the one-year period. See 38 C.F.R. § 3.156(b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). Accordingly, the November 2013 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.202, 20.1103. The instant claim for service connection for a left foot disability was received in April 2016. Since the November 2013 rating decision, the Veteran submitted additional evidence, including a June 2019 private medical opinion from Dr. M.B. explaining that the Veteran has walked with an antalgic gait to compensate for his pain in his ankle, knees and hips, in support of the premise that such overcompensation can aggravate a disability (in the opinion specifically directed to the lumbar spine disability). This evidence is new in that it was not previously of record at the time of the November 2013 rating decision. Additionally, the newly submitted evidence is not cumulative or redundant of evidence already of record. Given the standard set forth in Shade, outlined above, the Board finds that the additional evidence is new and material within the meaning of 38 C.F.R. § 3.156, warranting reopening of the claim of service connection for a left foot disability. 2. Entitlement to service connection for a left arm disability. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table decision). Review of the evidence of record reveals no evidence of, or allegation of functional impairment due to, a left arm disability (separate and distinct from a left shoulder disability). See January 2018 Board decision (denying entitlement to service connection for a left shoulder disorder). Without competent evidence diagnosing a left arm disability or any functional impairment of the left arm (separate and distinct from the previously denied left shoulder disability) during the appeal period, service connection cannot be granted. Congress has specifically limited entitlement to service connection for disease or injury incurred or aggravated in service to cases where such incidents have resulted in disability. 38 U.S.C. § 1131. Where, as here, competent evidence does not establish the disability for which service connection is sought, there can be no valid claim for service connection. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for a right shoulder disability. 4. Entitlement to service connection for a neck/upper back disability. The Veteran has made a bare assertion of a nexus between active service and his claimed right shoulder and neck/upper back disabilities; the reasons he believes each condition to be related to service have not been specified, and he has not offered any clarification. As a preliminary matter, the Board notes that the evidence of record reflects that these disabilities did not manifest until well after separation from service. The Board further notes that there were no complaints regarding the right shoulder or the neck/upper during the Veteran’s service. See, e.g., October 1983 report of medical history (denying complaints of painful or “trick” shoulder or elbow, recurrent back pain). Post-service treatment records reflect diagnoses of cervical spine osteoarthritis and degenerative change in the right acromioclavicular joint. See May 2010 imaging; August 2016 VA examination. No medical professional has opined that the Veteran’s right shoulder or neck/upper back disability are related to service on any basis. The Veteran has asserted a belief in connection, but has offered no evidence in support of this belief, or even defined a theory of entitlement. The Veteran is a lay person, and not competent to offer a probative opinion on nexus in these matters. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The Board is cognizant that the duty to assist includes providing an examination when one is required by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran had not been afforded an examination or opinion in connection with the claims for service connection for a right shoulder or neck/upper back disability. A medical examination is required only where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service; and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. See McLendon, 20 Vet. App. at 83. Here, the evidence shows right shoulder and neck/upper back disabilities. However, there is no evidence that even suggests an etiological relationship between these conditions and the Veteran’s active duty service. The Veteran does not assert that his right shoulder or neck/upper back disabilities have been chronic since service, but rather, he asserts without any support that his current symptoms are related in some way to his active duty service. As such, this belief is neither competent nor probative, and alone, does not raise any obligation on the part of VA to obtain a medical opinion at this time. 38 C.F.R. § 3.159(c)(4). In the absence of evidence, there cannot be equipoise, and there can be no resolution of doubt. The Veteran still ultimately bears some burden of production. 38 U.S.C. § 5107(a); Cromer v. Nicholson, 455 F.3d 1346 (Fed. Cir. 2006). As there is no evidence to support any finding of a nexus between service, and right shoulder or neck/upper back disability, entitlement to the benefits sought are not warranted. Increased Rating 5. Entitlement to a rating in excess of 10 percent for tinnitus. Tinnitus is rated under Diagnostic Code 6260, which includes a 10 percent rating for recurrent tinnitus with no higher ratings available. Notes for this diagnostic code state a separate evaluation may be assigned under Diagnostic Code 6100 (hearing loss), Diagnostic Code 6200 (chronic suppurative otitis media, mastoiditis, or cholesteatoma), and Diagnostic Code 6204 (peripheral vestibular disorders); assign only a single evaluation for recurrent tinnitus, whether the sound is perceived in one ear, both ears, or in the head; and do not evaluate objective tinnitus (in which the sound is audible to other people and has a definable cause that may or may not be pathologic) under this Diagnostic Code, but evaluate it as part of any underlying condition causing it. The Veteran is currently assigned a 10 percent rating for his service-connected tinnitus. There is no legal basis for assigning a higher rating under Diagnostic Code 6260, and no other diagnostic code may be considered. See Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006); Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) (when a condition is specifically listed in the rating schedule, it may not be rated by analogy and should be rated under the diagnostic code that specifically pertains to it). 6. Entitlement to a rating in excess of 10 percent for bilateral hearing loss. The VA Schedule for Rating Disabilities (Rating Schedule) provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based on testing (by a state-licensed audiologist) including Puretone thresholds and speech discrimination (Maryland CNC test). See 38 C.F.R. § 4.85. Table VII is used to determine the rating assigned by combining the Roman numeral designations for hearing impairment in each ear. Ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometry evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). On August 2016 VA audiological evaluation, puretone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 RIGHT 20 20 25 25 LEFT 25 20 35 30 The average puretone thresholds were 23 in the right ear and 28 in the left ear. Speech audiometry revealed speech recognition ability of 94 percent in the right ear and 98 percent in the left ear. Appling the results of the August 2016 examination to Table VI produces a finding that the Veteran had Level I hearing acuity in the right ear, and Level I hearing acuity in the left ear, warranting a noncompensable rating. An exceptional pattern of hearing impairment is not demonstrated. 38 C.F.R. § 4.86. As noted above, ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometry evaluations are rendered. On this basis, the Veteran is not entitled to a rating in excess of 10 percent as the preponderance of the evidence is against the claim. The Board acknowledges the Veteran’s reports that his hearing loss results in having to ask others to repeat themselves frequently, as well as difficulty hearing when background noise is present. See August 2016 VA examination. These types of functional impairments are contemplated by the Rating Schedule. Therefore, a rating in excess of 10 percent for the Veteran’s bilateral hearing loss is not warranted. Effective Date 7. Entitlement to an effective date earlier than April 13, 2016 for the award of service connection for right hip degenerative joint disease with limitation of extension. 8. Entitlement to an effective date earlier than April 13, 2016 for the award of service connection for right hip impairment of the thigh. Generally, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim, or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The effective date of an original award of direct service connection is the day following separation from active service or date entitlement arose if the claim is received within one year after separation from service; otherwise, it is the date of receipt of claim, or date entitlement arose, whichever is later. Id. Moreover, the Court of Appeals for Veterans Claims has determined that the effective date of an award of service connection is not based upon the date of the earliest medical evidence demonstrating entitlement, but on the date that the application upon which service connection was ultimately awarded was filed with VA. See Lalonde v. West, 12 Vet. App. 377, 380 (1999). (“[T]he effective date of an award of service connection is not based on the date of the earliest medical evidence demonstrating a causal connection, but on the date that the application upon which service connection was eventually awarded was filed with VA.”) Effective March 24, 2015, a change in regulation requires claims to be filed on standard forms, eliminating constructive receipt of claims and informal claims. See 38 C.F.R. §§ 3.1(p), 3.150, 3.155, 3.160(a). Instead of informal claims, the new regulation provides that a claimant may request an application for benefits, upon receipt of which, the Secretary shall notify the claimant of the information necessary to complete the application form or form prescribed by the Secretary. 38 C.F.R. § 3.155 (a). Non-standard narrative communications/submissions - previously construed as informal claims – will be considered a request for an application for benefits. Standard Claims and Appeals Forms, 79 Fed. Reg. 57660, 57661 (Sept. 25, 2014) (where a claimant submits an informal claim, VA will deem it a request for an application for benefits). The regulation also allows a claimant to submit an intent to file a claim, and VA may recognize the receipt date of the intent to file a claim as the date of claim so long as VA receives the successfully completed claim form within a year. 38 C.F.R. § 3.155(b). There are three ways in which a claimant may submit an intent to file a claim: (i) saved electronic application - when an application otherwise meeting the requirements of paragraph (b) is electronically initiated and saved in a claims-submission tool with a VA web-based electronic claims application system, (ii) written intent, signed and dated on the intent to file a claim form prescribed by the Secretary, and (iii) oral intent communicated to designated VA personnel, recorded in writing, and documented in the claimant's records. Id. A review of the record reflects that the Veteran filed an intent to file a claim for compensation on April 13, 2016. See April 13, 2016 RO letter. The letter advised the Veteran that all claims must be submitted on a standardized form, and notified the Veteran of the information necessary to file a claim. Subsequently, on April 28, 2016, the Veteran submitted a properly completed VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, seeking, in part, a claim for the right hip. A November 2016 rating decision awarded service connection for right hip degenerative arthritis limitation of extension, and right hip impairment of the thigh, and assigned an effective date of April 13, 2016, noting that was the date of his intent to file a claim of entitlement to compensation. In this case, the RO assigned the correct effective date of April 13, 2016 for the award of service connection for right hip degenerative arthritis based on limitation of extension, and right hip impairment of the thigh. The record reflects the Veteran submitted an intent to file a claim for compensation on April 13, 2016, and within one year of his intent to file a claim he filed a standardized claim for compensation for the right hip. The Veteran does not assert, and the evidence does not otherwise reflect, that he filed an intent to file a claim for compensation prior to April 13, 2016. Thus, entitlement to an earlier effective date is denied. REASONS FOR REMAND 9. Entitlement to an initial compensable rating for right hip degenerative arthritis impairment of the thigh is remanded. 10. Entitlement to an initial rating in excess of 10 percent for right hip degenerative arthritis with limitation of extension is remanded. 11. Entitlement to a rating in excess of 10 percent for right hip degenerative arthritis with limitation of flexion is remanded. 12. Entitlement to a rating in excess of 20 percent for left ankle degenerative joint disease is remanded. 13. Entitlement to a rating in excess of 10 percent for left knee chondromalacia and degenerative joint disease is remanded. The Veteran was most recently afforded a VA examination to evaluate the current severity of his right hip, left ankle, and left knee disabilities in August 2016. After a review of the examinations, the Board finds that the examination reports are insufficient in light of the United States Court of Appeals for Veterans Claims (Court) decisions in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). On remand, a current VA examination that complies with Correia and also addresses functional loss is warranted. In addition, the Veteran’s credible complaints of instability due to the left knee and/or ankle should be acknowledged. See, e.g., August 2016 VA examination (noting the Veteran’s complaint of falls due to left knee/ankle pain and weakness). 14. Entitlement to service connection for headaches is remanded. 15. Entitlement to service connection for a lumbar spine disability is remanded. 16. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran contends that his headaches are secondary to his service-connected tinnitus and his acquired psychiatric disorder and has submitted supporting private medical evidence. See June 2019 Disability Benefits Questionnaire (DBQ). The Veteran also contends that his acquired psychiatric disorder is directly related to service and/or secondary to his service-connected disabilities and has submitted supporting private medical evidence. See June 2019 private H.H.G., Ph.D. medical opinion. In addition, the Veteran contends his lumbar spine disability is secondary to his service-connected disabilities. See June 2019 private Dr. M.B. medical opinion. The Veteran has not been afforded a VA examination regarding the acquired psychiatric disorder or headaches claims, and the Board finds that the existing record triggers VA’s duty to obtain one. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). While the Veteran was afforded a VA examination regarding the lumbar spine disability in August 2016, the opinion did not address secondary causation, and the Veteran should be afforded another examination to determine the nature and etiology of his lumbar spine disability. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). 17. Entitlement to service connection for hypertension is remanded. The record shows that during active duty service, the Veteran had several elevated blood pressure readings, including in November 1980 (130/88), June 1984 (162/54, 140/52), November 1985 (126/94) and July 1986 (140/98). Moreover, the post-service evidence of record shows that the Veteran has been diagnosed with hypertension. See May 2005 VA treatment records. He has not yet been afforded a VA examination and the Board finds that the existing record triggers VA’s duty to obtain one. See 38 U.S.C. § 5103A(d); McLendon, 20 Vet. App. at 83. 18. Entitlement to service connection for a left foot disability is remanded. The Board finds that this matter must be remanded for an examination as to the etiology of the Veteran’s left foot disability. See Barr, 21 Vet. App. at 312; see also El-Amin, 26 Vet. App. at 140-41. 19. Entitlement to TDIU is remanded. Evidence associated with the claims file has raised the matter of entitlement to TDIU. Action on the TDIU claim is deferred pending the above development. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); see also Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Schedule the Veteran for a VA examination to determine the onset and etiology of headaches. The Veteran’s claims file must be provided to the examiner in conjunction with the requested opinion. All indicated tests and studies should be conducted, and all findings reported in detail. The examiner is asked to address the following: (a) Please opine as to whether it is at least as likely as not that the Veteran’s headaches/functional impairment had its onset or is otherwise related to the Veteran’s active service. (b) Whether his headaches disability/functional impairment diagnosed is proximately due to his service-connected tinnitus or nonservice-connected acquired psychiatric disorder; or (c) Whether his headaches disability/functional impairment diagnosed has been by his service-connected tinnitus or nonservice-connected acquired psychiatric disorder. A complete rationale should be given for all opinions and conclusions expressed. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Please note that it is not necessary that the service-connected tinnitus be diagnosed or even service-connected at the time the headaches disability/functional impairment is incurred to establish service connection, and reliance on this fact will render any secondary opinion inadequate. The examiner is asked to address the private medical opinion from Dr. M.B. submitted by the Veteran in June 2019. 3. Schedule the Veteran for a VA examination to determine the onset and etiology of his lumbar spine disability. The Veteran’s claims file must be provided to the examiner in conjunction with the requested opinion. All indicated tests and studies should be conducted, and all findings reported in detail. For each lumbar spine disability diagnosed, the examiner should opine as to whether it is at least as likely as not that such disability: (a) Whether any lumbar spine disability/functional impairment diagnosed is proximately due to his service-connected right hip, left hip, left knee, right knee and/or left ankle disability; or (b) Whether any lumbar spine disability/functional impairment diagnosed has been aggravated by his service-connected right hip, left hip, left knee, right knee and/or left ankle disability. A complete rationale should be given for all opinions and conclusions expressed. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Please note that it is not necessary that the service-connected disabilities be diagnosed or even service-connected at the time the lumbar spine disability/functional impairment is incurred to establish service connection, and reliance on this fact will render any secondary opinion inadequate. The examiner is asked to specifically address the June 2019 private medical opinion by Dr. M.B. submitted by the Veteran in June 2019. 4. Schedule the Veteran for a VA examination to determine the onset and etiology of acquired psychiatric disorder. The Veteran’s claims file must be provided to the examiner in conjunction with the requested opinion. All indicated tests and studies should be conducted, and all findings reported in detail. The examiner is asked to address the following: (a) Please opine as to whether it is at least as likely as not that the Veteran’s acquired psychiatric disorder/functional impairment had its onset or is otherwise related to the Veteran’s active service. (b) Whether any acquired psychiatric disorder/functional impairment diagnosed is proximately due to his service-connected right hip, left hip, left knee, right knee, left ankle disability, bilateral hearing loss, tinnitus and/or left ankle scar; or (c) Whether any acquired psychiatric disorder/functional impairment diagnosed has been aggravated (worsened beyond natural progression) by his service-connected right hip, left hip, left knee, right knee, left ankle disability, bilateral hearing loss, tinnitus and/or left ankle scar. A complete rationale should be given for all opinions and conclusions expressed. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Please note that it is not necessary that the service-connected disabilities be diagnosed or even service-connected at the time the acquired psychiatric disorder/functional impairment is incurred to establish service connection, and reliance on this fact will render any secondary opinion inadequate. The examiner is asked to specifically address the private medical opinion from H.H.G., Ph.D. submitted in June 2019. 5. Schedule the Veteran for a VA examination to determine the onset and etiology of his hypertension. The Veteran’s claims file must be provided to the examiner in conjunction with the requested opinion. All indicated tests and studies should be conducted, and all findings reported in detail. The examiner should opine as to whether it is at least as likely as not that the Veteran’s hypertension had its onset in service or is otherwise related to service, specifically addressing the elevated blood pressure readings found during active service. A detailed rationale for any opinion expressed should be provided. If an opinion cannot be rendered without resorting to speculation, that should be explained. 6. Then schedule the Veteran for a VA examination to determine the nature and etiology of his left foot disability. The claims file must be provided to the examiner in conjunction with the requested opinion. All indicated tests and studies should be conducted, and all findings reported in detail. The examiner is asked to address the following: (a) Please opine as to whether it is at least as likely as not that the Veteran’s left foot disability disability/functional impairment had its onset or is otherwise related to the Veteran’s active service. (b) Whether any left foot disability/functional impairment diagnosed is proximately due to his service-connected right hip, left hip, left knee, right knee and/or left ankle disability; or (c) Whether any left foot disability/functional impairment diagnosed has been aggravated by his service-connected right hip, left hip, left knee, right knee and/or left ankle disability. A complete rationale should be given for all opinions and conclusions expressed. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Please note that it is not necessary that the service-connected disabilities be diagnosed or even service-connected at the time the left foot disability/functional impairment is incurred to establish service connection, and reliance on this fact will render any secondary opinion inadequate. 7. Schedule the Veteran for a VA examination to determine the current nature and severity of his right hip, left knee and left ankle. The claims file, to include a copy of this remand, must be made available to and reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. The examiner is asked to address the following: (a) Full range of motion testing must be performed. The joints involved should be tested in (1) active motion, (2) passive motion, (3) in weight-bearing, (4) in nonweight-bearing. Please specify range of motion measurements in all areas outlined above. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. Considering the Veteran’s reported history, please provide an opinion describing functional impairment of the Veteran’s right hip, left knee and left ankle due to flare-ups, accounting for pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report such impairment in terms of additional degrees of limitation of motion. If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale for this conclusion. The examiner is asked to specifically address the Veteran’s complaints of instability of the hip and knee on August 2016 VA examination. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Marley, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.