Citation Nr: 20008463 Decision Date: 01/31/20 Archive Date: 01/31/20 DOCKET NO. 18-53 910 DATE: January 31, 2020 ORDER New and material evidence having been received by VA sufficient to reopen a previously-denied claim to establish service connection for a heart disability, the claim is reopened. New and material evidence having been received by VA sufficient to reopen a previously-denied claim to establish service connection for obstructive sleep apnea, the claim is reopened. Entitlement to service connection for major depressive disorder with anxious distress features is granted. Entitlement to service connection for obstructive sleep apnea, is granted. Entitlement to service connection for a headache disability, diagnosed as tension headaches, is granted. REMANDED Entitlement to service connection for an acquired psychiatric disability other than major depressive disorder with anxious distress features is remanded. Entitlement to service connection for a respiratory disability (claimed as bronchitis) is remanded. Entitlement to service connection for a sinus disability, diagnosed as chronic sinusitis, is remanded. Entitlement to service connection for a heart disability is remanded. Entitlement to service connection for a bilateral foot disability is remanded. Entitlement to an evaluation in excess of 10 percent for service-connected hypertension is remanded. Entitlement to an increased evaluation for a service-connected right shoulder disability characterized as “right shoulder, postoperative,” (formerly characterized as right shoulder bursitis, and hereinafter referred to a service-connected right shoulder disability), currently evaluated 20 percent disabling prior to May 20, 2014, 10 percent disabling from May 20, 2014, to April 28, 2015, and 20 percent disabling from April 29, 2015, to the present, is remanded. Entitlement to an increased initial evaluation for service-connected surgical scars of the right shoulder, currently evaluated noncompensably (zero percent) disabling prior to April 29, 2015, and 20 percent disabling, thereafter, is remanded. Entitlement to an evaluation in excess of 20 percent for service-connected spondylosis and degenerative disc disease of the lumbosacral spine is remanded. Entitlement to an evaluation in excess of 10 percent for service-connected right knee patellofemoral syndrome is remanded. Entitlement to an evaluation in excess of 10 percent for service-connected left knee patellofemoral syndrome is remanded. Entitlement to an evaluation in excess of 10 percent for service-connected right carpal tunnel syndrome is remanded. Entitlement to an evaluation in excess of 10 percent for service-connected left carpal tunnel syndrome is remanded. Entitlement to an evaluation in excess of 10 percent for service-connected residuals of a right wrist scaphoid fracture is remanded. Entitlement to an evaluation in excess of 10 percent for service-connected right ankle tendonitis is remanded. Entitlement to an evaluation in excess of 10 percent for service-connected left ankle tendonitis is remanded. Entitlement to an earlier effective date for the grant of service connection for hypertension is remanded. Entitlement to an earlier effective date for the grant of service connection for surgical scars of the right shoulder is remanded. Entitlement to an earlier effective date for the grant of service connection for spondylosis and degenerative disc disease of the lumbosacral spine is remanded. Entitlement to an earlier effective date for the grant of service connection for right knee patellofemoral syndrome is remanded. Entitlement to an earlier effective date for the grant of service connection for left knee patellofemoral syndrome is remanded. Entitlement to an earlier effective date for the grant of service connection for right carpal tunnel syndrome is remanded. Entitlement to an earlier effective date for the grant of service connection for left carpal tunnel syndrome is remanded. Entitlement to an earlier effective date for the grant of service connection for residuals of a right wrist scaphoid fracture is remanded. Entitlement to an earlier effective date for the grant of service connection for right ankle tendonitis is remanded. Entitlement to an earlier effective date for the grant of service connection for left ankle tendonitis is remanded. Entitlement to a total evaluation based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. A June 2006 rating decision denied the Veteran's claims to establish service connection for a heart disability and obstructive sleep apnea; the Veteran did not appeal that decision, nor was any new and material evidence submitted within the appeal period. 2. Evidence received by VA since the final June 2006 rating decision raises a reasonable possibility of substantiating the issues to establish service connection for a heart disability and obstructive sleep apnea. 3. The most probative evidence reflects that major depressive disorder with anxious distress features had its onset during the Veteran’s active duty and continued, uninterrupted, until the present. 4. The most probative evidence reflects that the Veteran’s obstructive sleep apnea was caused or aggravated by her service-connected disabilities. 5. The most probative evidence reflects that the Veteran’s tension headaches were caused or aggravated by her service-connected disabilities. CONCLUSIONS OF LAW 1. The June 2006 rating decision is final with respect to the Veteran's claims to establish service connection for a heart disability and obstructive sleep apnea. 38 U.S.C. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103 (2019). 2. Evidence received to reopen the issues of entitlement to service connection for a heart disability and obstructive sleep apnea is new and material, and the issues are reopened. 38 U.S.C. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156(a) (2019). 3. The criteria to establish service connection for major depressive disorder with anxious distress features are met. 38 U.S.C. §§ 1110, 1111, 1112, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2019). 4. The criteria to establish service connection for obstructive sleep apnea are met. 38 U.S.C. §§ 1110, 1111, 1112, 5103A, 5107 (West 2002); 38 C.F.R. § 3.310 (2019). 5. The criteria to establish service connection for tension headaches are met. 38 U.S.C. §§ 1110, 1111, 1112, 5103A, 5107 (West 2002); 38 C.F.R. § 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from April 1986 to June 2006, to include to include service in Southwest Asia Theater of operations during the Persian Gulf War. This matter comes to the Board of Veterans' Appeals (Board) from a September 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) of the Veterans Benefits Administration (VBA), which is the Agency of Original Jurisdiction (AOJ). The Veteran expressed timely disagreement with this determination, and the present appeal ensued. Characterization of issues on appeal In January 2014, the Veteran filed claims, among others, seeking increased evaluations for several service-connected disabilities. These claims were initially adjudicated in a July 2014 rating decision that, in pertinent part, recharacterized the Veteran’s service-connected right shoulder disability, assigned “staged” evaluations for such, and established service connection for surgical scars of the right shoulder. The Veteran was notified of the July 2014 rating decision in August 2014. The Veteran did not express disagreement with the AOJ’s determinations conveyed in the July 2014 rating decision. Instead, she filed additional claims for disability benefits in April 2015, including claims seeking increased evaluations for several service-connected disabilities that were adjudicated by the AOJ in the July 2014 rating decision. In developing the Veteran’s April 2015 claims, the Veteran was provided VA examinations in July 2015 – within the appeal period of the July 2014 rating decision. In a September 2015 rating decision, the AOJ adjudicated the Veteran’s April 2015 claims and readjudicated her January 2014 claims, which thereafter resulted in partial allowances and “staged” evaluations of the Veteran’s service-connected right shoulder disability and surgical scars. In April 2016, the Veteran, through her private attorney, expressed disagreement with the September 2015 rating decision, and the present appeal ensued. In light of above, the Board has recharacterized the issues on appeal as stated on the title page of this decision to reflect the issue recharacterization and “staged” evaluations. See Hart v. Mansfield, 21 Vet. App. 505 (2007); AB v. Brown, 6 Vet. App. 35, 38-39 (1993). Further, the Board observes that the Veteran’s claims seeking increased evaluations for her service-connected hypertension, surgical scars of the right shoulder, bilateral carpal tunnel syndrome, and disabilities of the right shoulder, right wrist, and ankles, stem from her January 2014 claims. 38 C.F.R. § 3.156(b) (2019); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). Also, the Board observes that the Veteran expressed disagreement with the effective date of all of the Veteran’s service-connected disabilities in the April 2016 Notice of Disagreement. The Board notes that the AOJ’s September 2015 rating decision, which subsumed the July 2014 rating decision for any common issues, only assigned effective dates impacting two of the Veteran’s service-connected disabilities – her recharacterized right shoulder disability and right shoulder surgical scars. Concerning the former issue, which is a “traditional” increased and staged evaluation appeal, the Veteran’s disagreement with the effective dates assigned for the staged evaluations for her right shoulder disability will be encompassed in the appeal seeking an increased evaluation for this disability. To the contrary, the latter issue is seeking an increased initial staged evaluation. As such, the Veteran’s disagreement with the assigned effective dates in connection with this issue are two-fold: (1) challenging the effective date assigned for the “staged” initial evaluation and (2) challenging the effective date assigned for the grant of service connection for the underlying disability. As with the prior issue, the Veteran’s disagreement with the effective date assigned for the staged initial evaluation for her right shoulder scars will be encompassed in the appeal seeking an increased evaluation for this disability; however, her challenge of the effective date assigned for the grant of service connection for this underlying disability is a wholly separate issue that is properly before the Board, and this issue has been added to the title page of this decision. Further, after the AOJ certified the Veteran’s appeal to the Board, her private attorney filed several submissions for consideration in readjudicating the appeal, including a VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Individual Unemployability) and waiver of the AOJ’s initial review of the additional evidence. To this point, the Veteran’s TDIU claim, although recently filed, is considered to be part and parcel of her pending appealed issues seeking increased evaluations – the earliest of which before the Board was filed in January 2014. As such, the issue of entitlement to a TDIU is properly before the Board, and the Board may review the October 2019 submissions from the Veteran’s private attorney. 38 C.F.R. §§ 19.37(b), 20.1304(c) (2019); Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Also, in April 2015, the Veteran filed a claim to establish service connection for “depression/anxiety.” The AOJ bifurcated this claim and separately developed and adjudicated claims to establish service connection for anxiety and depression. As will be further discussed below, the evidence of record substantiates one of these issues; however, additional development is necessary prior to readjudication of the other. In light of the evidence on which the Board is basing the service connection allowance, the scope of that issue will remain narrow; however, the Board has expanded and recharacterized the Veteran’s “anxiety” claim to acknowledge the psychiatric disability for which service connection is being established and to expand the remaining claim to encompass any other acquired psychiatric disability present during the appeal period. Clemons v. Shinseki, 23 Vet. App. 1 (2009); Tyrues v. Shinseki 23 Vet. App. 166, 178-79 (2009) (en banc), aff’d, 631 F.3d 1380 (Fed. Cir. 2011), vacated on other grounds, 132 S. Ct. 75 (2012). Preliminary matter The record unambiguously reflects that the Veteran married during her active duty, and thereafter, she used a hyphenated last name. However, the evidence dated after her marriage includes several official records from the Department of the Navy, the Department of Defense, and her private attorney which use several variations of her maiden and married names. To avoid confusion, the caption of this decision uses the Veteran’s hyphenated married name, and her maiden name and all variations included within her official records have been added as Also Knows As (A.K.A.) names. Service Connection and New and Material Evidence Pertinent procedural regulations provide that “[n]othing in [38 U.S.C. § 5103A] shall be construed to require [VA] to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in [38 U.S.C. § 5108].” 38 U.S.C. § 5103A (f) (West 2002). Reopening a claim for service connection which has been previously and finally disallowed requires that new and material evidence be presented or secured since the last final disallowance of the claim. 38 U.S.C. § 5108; Evans v. Brown, 9 Vet. App. 273, 285 (1996). Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2019). 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. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a) (2019). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). If a chronic disease, is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309(a). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2019). New evidence means existing evidence not previously submitted to VA. 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) (2019). In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant’s injury or disability, even where it would not be enough to convince the Board to grant a claim. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). In Elkins v. West, 12 Vet. App. 209 (1999), the Court of Appeals for Veterans Claims (the Court) held the Board must first determine whether the appellant has presented new and material evidence under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C. § 5108. Then, if new and material evidence has been submitted, the Board may proceed to evaluate the merits of the claim, but only after ensuring that VA’s duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The Court has also held that the law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2012). Even if no appeal is filed, a rating decision is not final if new and material evidence is submitted within the appeal period and has not yet been considered by VA. 38 C.F.R. § 3.156(b) (2019); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). 1. Whether new and material evidence has been received by VA sufficient to reopen a previously-denied claim to establish service connection for a heart disability 2. Whether new and material evidence has been received by VA sufficient to reopen a previously-denied claim to establish service connection for obstructive sleep apnea In the interest of economy, the Board will discuss the petitions to reopen these previously-denied claims together. As will be fully addressed below, the Board concludes that, since the prior final denial, VA has received evidence which is new and material and raises a reasonable possibility of substantiating the issues. As such, these issues are reopened. Pertinently, the Veteran’s initial claims to establish service connection for a heart disability and obstructive sleep apnea were previously denied by the AOJ in a June 2006 rating decision because evidence of record did not reflect a diagnoses of obstructive sleep apnea or any heart disability underlying the Veteran’s atrial regurgitation – which was noted to be a laboratory finding. The Veteran did not express disagreement with the determinations regarding these issues or submit new and material evidence pertinent to either issue during the appeal period. As such, the June 2006 rating decision is final with respect to these issues. 38 U.S.C. § 7105 (c) (West 2002); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103 (2019). In April 2015, the Veteran filed petitions to reopen these previously-denied claims. Throughout the pendency of the current appeal, the AOJ has stated that these previously-denied claims have not been reopened because new and material evidence sufficient to do so has not been received by VA. Regardless, the Board is not bound by those determinations as to whether the claims should be reopened, and must nevertheless consider whether new and material evidence has been received. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). The bases of the prior final denial by the AOJ in June 2006 are articulated, above. In order for the previously-denied claims to be reopened, evidence must have been added to the record since the June 2006 rating decision that addresses these bases. Pertinently, evidence received by VA since the June 2006 rating decision includes (1) a September 2014 VA echocardiogram report reflecting diagnoses of concentric left ventricular hypertrophy resulting in several cardiac dysfunctions and insufficiencies, (2) a June 2019 Disability Benefits Questionnaire (DBQ) completed by a private clinician noting a diagnosis of obstructive sleep apnea confirmed by a June 2015 sleep study, and (3) a June 2019 statement from a private clinician reflecting an opinion that the Veteran’s obstructive sleep apnea is aggravated beyond the normal progression of the disease by the Veteran’s service-connected disabilities, the medications prescribed for treatment of such, and her major depressive disorder with anxious distress features. As will be further discussed below, the Board concludes that service connection for sleep apnea is warranted. The above-mentioned evidence is “new,” as it was not been previously considered by VA, and “material” as it raises the reasonable possibility of substantiating the previously-denied issues. The Board thus finds that new and material evidence has been received by VA sufficient to reopen the issues to establish service connection for a heart disability and obstructive sleep apnea since the prior final denials in June 2006. On that basis, the issues are reopened, and the appeal is granted to that extent only. The merits of the Veteran’s appealed issues to establish service connection for obstructive sleep apnea and a heart disability will be further discussed below. 3. Entitlement to service connection for major depressive disorder with anxious distress features The Veteran’s service treatment records include several reports of “past depression;” however, no psychiatric disability was diagnosed during her active duty. This evidence suffices element (2) to establish service connection under the theory of direct service connection. In support of the Veteran’s appeal, her private attorney has submitted a June 2018 VA psychiatric DBQ and February 2019 statement from a private clinician. These records reflect a diagnosis of major depressive disorder with anxious distress features and the clinician’s opinion that this disability was at least as likely as not present during the Veteran’s active duty and has continued, uninterrupted, since that time. This evidence amply demonstrates elements (1) and (3) to establish direct service connection for this disability, and there is no evidence to the contrary. In light of above, service connection for major depressive disorder with anxious distress features is warranted. 38 C.F.R. § 3.303(d) (2019). In passing, the Board observes that the private clinician’s February 2019 statement also included the opinion that the Veteran’s major depressive disorder with anxious distress features was at least as likely as not aggravated by all 16 of her service-connected disabilities. While this opinion clearly suffices element (3) to establish service connection for this disability under the theory of secondary service connection, the Board is granting this issue under the theory of direct service connection, as it is the greater benefit. 4. Entitlement to service connection for obstructive sleep apnea, to include as secondary to a service-connected disability 5. Entitlement to service connection for a headache disability, diagnosed as tension headaches, to include as secondary to a service-connected disability As analysis of these issues entails application of identical laws to similar facts, the Board will discuss them together for the sake of economy. By virtue of the Board’s allowance of service connection for major depressive disorder with anxious distress features, the Veteran now has 17 service-connected disabilities, which also include spondylosis and degenerative disc disease of the lumbosacral spine and hypertension. As such, element (2) to establish service connection under the theory of secondary service connection has been demonstrated. In support of the Veteran’s appeal, her private attorney submitted June 2019 VA sleep disease and headache DBQs and separate June 2019 statements from a private clinician. These records reflect a diagnoses of tension headaches and obstructive sleep apnea and the clinician’s opinions that (1) the Veteran’s tension headaches were at least as likely as not aggravated by her service-connected low back disability and hypertension, including the medications prescribes for symptoms of such, and (2) her obstructive sleep apnea is at least as likely as not aggravated by all 17 of her service-connected disabilities, including the medications prescribes for symptoms of such. This evidence amply demonstrates elements (1) and (3) to establish secondary service connection for these disabilities. There is no evidence to the contrary or evidence to substantiate the appealed issues under the theory of direct service connection, as would be the greater benefit. In light of above, service connection for tension headaches and obstructive sleep apnea is warranted. 38 C.F.R. § 3.310 (2019). REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disability other than major depressive disorder with anxious distress features 2. Entitlement to service connection for a respiratory disability (claimed as bronchitis) While the Veteran’s service treatment records include notations of psychiatric symptoms and bronchitis during her active duty, the record is devoid of any diagnosed respiratory disability or acquired psychiatric disability other than major depressive disorder with anxious distress features during the appeal period. However, there is an indication that the record for review by the Board is incomplete. In October 2019, the Veteran’s private attorney submitted an undated document that appears to be a printout from a Social Security Administration (SSA) website that includes her yearly earnings from 1975 to 2018 and includes the verbiage, “Your benefits are based on your earnings.” This evidence seems to indicate that the Veteran is in receipt of disability benefits from the SSA; however, it is unclear when or why these benefits were awarded, as the record is devoid of any SSA decision and the records on which it was based. The Board concludes that a remand is necessary to attempt to obtain and associate with the file and decision for SSA disability benefits and the records upon which was based, as the evidence therein is potentially pertinent to all of the Veteran’s appealed issues, especially the two enumerated above, where no diagnosis of either disability is currently evidenced. Additional reasons for remanding the issues enumerated be below will be discussed separately. 3. Entitlement to service connection for a sinus disability, diagnosed as chronic sinusitis 4. Entitlement to service connection for a heart disability The Veteran’s service treatment records include in-service reports of sinus symptoms and chest pain and a notation of atrial regurgitation within her initial post-service year. Also, the Veteran’s VA outpatient treatment records note diagnoses of chronic sinusitis, for which medications have been prescribed, and a September 2014 VA echocardiogram report reflecting diagnoses of concentric left ventricular hypertrophy resulting in several cardiac dysfunctions and insufficiencies. Despite this evidence, the Veteran has not been provided a VA examination to determine the nature, date of initial onset, and/or etiology of her asserted disabilities. In light the above evidence, the Board concludes that VA’s duty to assist the Veteran in substantiating her appeal by providing her a VA examination has been triggered, and thus, a remand is necessary. 5. Entitlement to service connection for a bilateral foot disability The Veteran’s service treatment records reflect her reports of experiencing foot pain and x-ray evidence of a bilateral plantar calcaneal spur. The Veteran was provided a VA foot examination in October 2018, and bilateral plantar and retrocalcaneal spurs and plantar fasciitis of the left foot were diagnosed. The October 2018 VA examiner opined that these disabilities were less likely as not the result of the Veteran’s service, stating that “During service, condition was acute only. There is no evidence of chronicity of care. A nexus has not been established.” The Board finds that the October 2018 VA examiner’s opinion is inadequate for the purpose of readjudicating the appeal issue. First, the opinion only references the etiology of one foot disability, although there are multiple current foot disabilities of record. Second, the stated rationale cites to no medical evidence, to include the fact that it that the Veteran had plantar calcaneal spurs during and since service. As such, a remand is necessary. 6. Entitlement to an evaluation in excess of 10 percent for service-connected hypertension 7. Entitlement to an increased evaluation for a service-connected right shoulder disability, currently evaluated 20 percent disabling prior to May 20, 2014, 10 percent disabling from May 20, 2014, to April 28, 2015, and 20 percent disabling from April 29, 2015, to the present 8. Entitlement to an increased initial evaluation for service-connected surgical scars of the right shoulder, currently evaluated noncompensably disabling prior to April 29, 2015, and 20 percent disabling, thereafter 9. Entitlement to an evaluation in excess of 20 percent for service-connected spondylosis and degenerative disc disease of the lumbosacral spine 10. Entitlement to an evaluation in excess of 10 percent for service-connected right knee patellofemoral syndrome 11. Entitlement to an evaluation in excess of 10 percent for service-connected left knee patellofemoral syndrome 12. Entitlement to an evaluation in excess of 10 percent for service-connected right carpal tunnel syndrome 13. Entitlement to an evaluation in excess of 10 percent for service-connected left carpal tunnel syndrome 14. Entitlement to an evaluation in excess of 10 percent for service-connected residuals of a right wrist scaphoid fracture 15. Entitlement to an evaluation in excess of 10 percent for service-connected right ankle tendonitis 16. Entitlement to an evaluation in excess of 10 percent for service-connected left ankle tendonitis The Veteran was most recently provided VA examinations to determine the frequency and severity of the symptoms attributable to her service-connected hypertension, right shoulder disability, surgical scars of the right shoulder, spondylosis and degenerative disc disease of the lumbosacral spine, patellofemoral syndrome of the knees, bilateral carpal tunnel syndrome, residuals of a right wrist scaphoid fracture, and tendonitis of the ankles in July 2015 – more than four years ago. In an October 2019 statement, the Veteran’s private attorney asserted that these disabilities have worsened since July 2015, which is supported by the Veteran’s VA outpatient treatment records. Further, the Board observes that the May 2014 and July 2015 VA examination reports are inadequate concerning the Veteran’s orthopedic issues. Specifically, while the May 2014 and July 2015 VA examination reports reflect that the Veteran was experiencing daily flare-ups of low back, knee, ankle, right shoulder, bilateral carpal tunnel, and right wrist symptoms, resulting in additional limitation of motion due to pain, weakness and fatiguability, this additional functional loss is not quantified as necessary per the Court’s holding in Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017). While the Board observes the difficulties in scheduling VA examination during any flare-ups of symptoms, the prior VA examination reports reflect that the Veteran experiences such flare-ups of each disability on a daily basis. In light of above, the Board concludes that a remand is necessary so that the Veteran may be provided contemporaneous VA examinations to determine the current frequency and severity of the manifestations of her service-connected hypertension, right shoulder disability, surgical scars of the right shoulder, spondylosis and degenerative disc disease of the lumbosacral spine, patellofemoral syndrome of the knees, bilateral carpal tunnel syndrome, residuals of a right wrist scaphoid fracture, and tendonitis of the ankles. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994). 17. Entitlement to an earlier effective date for the grant of service connection for hypertension 18. Entitlement to an earlier effective date for the grant of service connection for surgical scars of the right shoulder 19. Entitlement to an earlier effective date for the grant of service connection for spondylosis and degenerative disc disease of the lumbosacral spine 20. Entitlement to an earlier effective date for the grant of service connection for right knee patellofemoral syndrome 21. Entitlement to an earlier effective date for the grant of service connection for left knee patellofemoral syndrome 22. Entitlement to an earlier effective date for the grant of service connection for right carpal tunnel syndrome 23. Entitlement to an earlier effective date for the grant of service connection for left carpal tunnel syndrome 24. Entitlement to an earlier effective date for the grant of service connection for residuals of a right wrist scaphoid fracture 25. Entitlement to an earlier effective date for the grant of service connection for right ankle tendonitis 26. Entitlement to an earlier effective date for the grant of service connection for left ankle tendonitis As noted in the Introduction, in April 2016, the Veteran expressed timely disagreement with the assigned effective dates for her service-connected hypertension, surgical scars of the right shoulder, right shoulder disability, spondylosis and degenerative disc disease of the lumbosacral, patellofemoral syndrome of the knees, bilateral carpal tunnel syndrome, residuals of a right wrist scaphoid fracture, and tendonitis of the ankles. As discussed above, the Veteran’s disagreement with the “staged” evaluation and initial evaluation for her service-connected right shoulder disability and right shoulder surgical scars, respectively, will be addressed as part and parcel of her appealed issue seeking increased evaluations for these disabilities. However, her disagreement with the AOJ’s assignment of the date of service connection for the award of service connection for surgical scars of the right shoulder has not been readjudicated in a Statement of the Case (SOC), as is necessary under the governing laws. Similarly, while the AOJ’s September 2015 rating decision did not assign effective dates for the Veteran’s service-connected hypertension, spondylosis and degenerative disc disease of the lumbosacral, patellofemoral syndrome of the knees, bilateral carpal tunnel syndrome, residuals of a right wrist scaphoid fracture, and tendonitis of the ankles, the Board must assume that the Veteran, through her private attorney, was expressing disagreement with the effective dates assigned for these disabilities – the most recent of which were the assignment of the effective dates for service connection for each disability. As these issues do not appear in the electronic Veterans Appeals Control and Locator System (VACOLS) as appealed issues (currently or previously), the Board concludes that a remand is necessary so that the Veteran may be provided an SOC readjudicating them. 38 C.F.R. § 19.26 (2017); Manlincon v. West, 12 Vet. App. 238 (1999). 27. Entitlement to a TDIU As noted in the Introduction, the appeal period for consideration regarding the Veteran’s TDIU appeal is from January 15, 2014, to the present. The Board notes that the Veteran meets the criteria for a schedular TDIU during the entirety of the appeal period. 38 C.F.R. § 4.16(a) (2019). In support of her appeal, the Veteran’s private attorney has submitted February 2019 and June 2019 opinions from private clinicians which stand for the premise that her 17 service-connected disabilities, in concert, have prevented her from securing and maintaining a substantially gainful occupation from “at least April 29, 2015.” While the Board observes and appreciates the above opinions, the questions to be considered by the Board regarding this issue are not fully addressed, thereby. First, the Veteran’s formal TDIU claim reflects that she last worked as a personal caregiver in August 2012; however, there is no statement from her most recent employer concerning when or why that employment ceased. Further, the undated printout from the SSA website indicates that the Veteran continued to incur earnings after August 2012, although it is unclear from where these earnings came and/or whether they represent a substantially gainful occupation for any period under consideration. Possibly, the information to be requested from the SSA, noted above, will be helpful in addressing these issues. Further, the Board observes that the February 2019 and June 2019 opinions reflect that, despite her alleged inability to secure and maintain a substantially gainful occupation since “at least April 29, 2015,” she has been enrolled and thriving in educational pursuits during this period, although “she has no plan to use her degree.” See the February 2019 and June 2019 DBQs and private opinions. Finally, the Board observes that the Veteran’s TDIU appeal is inextricably intertwined with the implementations of the Board’s allowances and the readjudication of the issues remanded, herein. In light of the contradictory and outstanding pertinent evidence, cited above, and the critical development to be undertaken, the Board concludes that the Veteran’s TDIU appeal must be remanded. The matters are REMANDED for the following actions: 1. The AOJ must obtain and associate with the file all updated records of VA treatment. 2. The AOJ must request that the Veteran identify the names, addresses, and approximate dates of treatment for all of the non-VA health care providers who have treated her for her disabilities remanded by the Board. After securing appropriate release(s) from the Veteran, the AOJ must make two attempts to obtain any identified private treatment records which are not already associated with the file or make a formal finding that a second request for such records would be futile. The Veteran must be notified of the results of the record requests. If records are not received from any source, follow the notification procedures of 38 C.F.R. § 3.159(e). 3. The AOJ must obtain and associate with the claims file any decision concerning disability benefits from the Social Security Administration (SSA), to include the medical records on which that decision was based. If the search for such records has negative results, the claims file must be properly documented as to the unavailability of these records. 4. Thereafter, the AOJ must request that the Veteran be scheduled for an appropriate VA examination to evaluate her service-connected disabilities subject to this remand and to determine the nature and etiology of her alleged disabilities for which she is claiming service connection. The complete electronic record must be made available to, and reviewed by, the VA examiner prior to conducting the examination(s). All necessary tests and studies should be conducted. If it is determined that several VA examinations are necessary to complete these remand directives, such should be scheduled, and the Veteran should be notified of the time(s) and place(s) to report for such. After completion of the above, the VA examiner(s) are requested to address the following: a. The examiner(s) must describe the frequency and severity of all manifestations of the Veteran's service-connected hypertension, right shoulder disability, surgical scars of the right shoulder, spondylosis and degenerative disc disease of the lumbosacral spine, patellofemoral syndrome of the knees, bilateral carpal tunnel syndrome, residuals of a right wrist scaphoid fracture, and tendonitis of the ankles. *To the degree possible, it also would be helpful if the Veteran could be scheduled for VA examination(s) during a flare-up of her service-connected right shoulder disability, spondylosis and degenerative disc disease of the lumbosacral spine, patellofemoral syndrome of the knees, bilateral carpal tunnel syndrome, residuals of a right wrist scaphoid fracture, and tendonitis of the ankles. According to the prior VA examination reports of record, such flare-ups of each disability occur daily and last for several hours. *In addition to the information requested by the standard DBQ relating to disabilities of the shoulders, spine, knees, wrists, and ankles, the examiner must specifically address the following: - Provide findings for limitation of motion (expressed in degrees) as per each disability’s rating criteria for the Veteran's right shoulder, spine, knees, wrists, and ankles during a flare-up of symptoms, currently and retrospectively. In doing so, please review the prior VA examination reports (May 2014 and July 2015), and based on the information therein, provide the requested findings retrospectively. b. Identify or rule out diagnoses of the following: i. Any respiratory disability; ii. Any sinus disability; iii. Any psychiatric disability other than major depressive disorder with anxious distress features; iv. Any disability of either foot; v. Any heart disability. c. If diagnoses of any of the following are ruled out, such finding(s) must be reconciled with the medical evidence noting such disabilities: i. Concentric left ventricular hypertrophy (September 2014 VA echocardiogram report); ii. Bilateral plantar and retrocalcaneal spurs and plantar fasciitis of the left foot (October 2018 VA foot examination); iii. Chronic sinusitis (November 2010 VA treatment record). d. For each disability identified in any subpart of part (b), provide an opinion addressing whether such is at least as likely as not proximately due to, or the result of, any incident of the Veteran’s service. e. For each disability identified in any subpart of part (b), provide an opinion addressing whether such is at least as likely as not caused or aggravated by a service-connected disability. If the examiner cannot provide an opinion without resorting to mere speculation, this should be so stated along with supporting rationale. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 5. Thereafter, the AOJ must readjudicate the Veteran’s appealed issues seeking increased evaluations and service connection. If any benefit sought on appeal is not granted to the Veteran's satisfaction, a Supplemental Statement of the Case (SSOC) should be issued to the Veteran and her private attorney, and they should be afforded the requisite opportunity to respond. 6. The AOJ must issue the Veteran and her private attorney a Statement of the case (SOC) addressing the issues of (1) entitlement to an earlier effective date for the grant of service connection for hypertension, (2) entitlement to an earlier effective date for the grant of service connection for surgical scars of the right shoulder (3) entitlement to an earlier effective date for the grant of service connection for spondylosis and degenerative disc disease of the lumbosacral spine, (4) entitlement to an earlier effective date for the grant of service connection for right knee patellofemoral, (5) entitlement to an earlier effective date for the grant of service connection for left knee patellofemoral syndrome, (6) entitlement to an earlier effective date for the grant of service connection for right carpal tunnel syndrome, (7) entitlement to an earlier effective date for the grant of service connection for left carpal tunnel syndrome, (8) entitlement to an earlier effective date for the grant of service connection for residuals of a right wrist scaphoid fracture (9) entitlement to an earlier effective date for the grant of service connection for right ankle tendonitis, and (10) entitlement to an earlier effective date for the grant of service connection for left ankle tendonitis. Manlincon, 12 Vet. App. 238. The SOC should include a discussion of all relevant evidence considered and citation to all pertinent law and regulations. 7. Thereafter, the AOJ must complete any additional evidentiary development necessary to adjudicate the Veteran’s TDIU appeal, to specifically include collecting and verifying information concerning the Veteran’s complete educational and occupational history and scheduling her for appropriate VA examination(s). 8. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, readjudicate the Veteran's TDIU appeal in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and her private attorney should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Scott W. Dale, 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.