Citation Nr: 20046967 Decision Date: 07/14/20 Archive Date: 07/14/20 DOCKET NO. 18-51 191 DATE: July 14, 2020 ORDER A rating in excess of 10 percent for a right knee strain with patellofemoral pain syndrome and degenerative arthritis (right knee disability) is denied. A rating in excess of 10 percent for a left knee strain with patellofemoral pain syndrome and degenerative arthritis (left knee disability) is denied. A separate 10 percent rating for right knee instability under Diagnostic Code 5257, is granted, subject to the regulations governing the payment of monetary awards. A separate 10 percent rating for left knee instability under Diagnostic Code 5257, is granted, subject to the regulations governing the payment of monetary awards. An initial compensable rating for allergic rhinitis prior to August 7, 2017, is denied. A rating higher than 10 percent for allergic rhinitis, since August 7, 2017, is denied. The application to reopen a claim of service connection for a dental disorder is granted. Service connection for an acquired psychiatric disorder, diagnosed as a depressive disorder, is granted. REMANDED The issue of service connection for a right hand disability is remanded. The issue of service connection for a left hand disability is remanded. The issue of service connection for disorder of the right upper extremity is remanded. The issue of service connection for posttraumatic stress disorder (PTSD) is remanded. The issue of service connection for residuals of a traumatic brain injury (TBI) is remanded. The issue of service connection for a dental disorder is remanded. The issue of service connection for a skin disability, other than eczema, is remanded. FINDINGS OF FACT 1. The Veteran’s right knee disability did not more nearly approximate limitation of flexion to 30 degrees even considering pain and flare up symptoms; there was no limitation of extension; there was no right knee ankylosis, semilunar cartilage dislocation or removal, symptomatic tibia or fibula impairment, or genu recurvatum. 2. The Veteran’s right knee disability manifested by no worse than slight recurrent or lateral instability. 3. The Veteran’s left knee disability did not more nearly approximate limitation of flexion to 30 degrees even considering pain and flare up symptoms; there was no limitation of extension; there was no left knee ankylosis, semilunar cartilage dislocation or removal, symptomatic tibia or fibula impairment, or genu recurvatum. 4. The Veteran’s left knee disability manifested by no worse than slight recurrent or lateral instability. 5. Prior to August 7, 2017, the Veteran did not have greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side, without polyps, or with the existence of nasal polyps, associated with his allergic rhinitis. 6. Throughout the appeal, the Veteran has not had nasal polyps associated with his allergic rhinitis. 7. In an April 2013 rating decision, the RO denied service connection for a dental disorder. The Veteran received notice of the decision, did not appeal this decision, and new and material evidence was not received within one year after it was issued. 8. Evidence received since the April 2013 rating decision relates to an unestablished fact and raises a reasonable possibility of substantiating the claim of service connection for a dental disorder. 9. The evidence is at least evenly balanced as to whether the Veteran’s acquired psychiatric disorder, diagnosed as a depressive disorder, had its onset in service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for the right knee disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5003-5260, 5258, 5262-5263. 2. The criteria for a rating in excess of 10 percent for the left knee disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.45, 4.59, 4.71a, DCs 5003-5260, 5258, 5262-5263. 3. The criteria for a separate 10 percent rating, but no higher, for right knee instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.45, 4.59, 4.71a, DC 5257. 4. The criteria for a separate 10 percent rating, but no higher, for left knee instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.45, 4.59, 4.71a, DC 5257. 5. The criteria for an initial compensable rating for allergic rhinitis, prior to August 7, 2017, are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.16, 4.97, DC 6522. 6. The criteria for a rating in excess of 10 percent for allergic rhinitis, since August 7, 2017, are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.16, 4.97, DC 6522. 7. The April 2013 rating decision that denied service connection for a dental disorder is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 20.302, 20.1103. 8. Since the April 2013 rating decision, new and material evidence has been received to reopen the claim of service connection for a dental disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 9. The criteria for service connection for an acquired psychiatric disorder, diagnosed as a depressive disorder, are met. 38 U.S.C. § 1131; 38 C.F.R. § 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1976 to September 1980. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from May 2016, October 2016, and November 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In July 2017, a Decision Review Officer (DRO) informal conference report was associated with the record. In a September 2018 rating decision, the DRO granted a temporary total rating for convalescence following the Veteran’s surgeries for his right and left knee disabilities from May 4, 2017, to August 30, 2017. As the Veteran received the maximum disability rating during that period, there is no issue in controversy for that period, and it will not be discussed further. In January 2019, the Veteran presented testimony before the Board. In April 2019, the Board remanded the Veteran’s appeal for further development. The Veteran’s appeal was, in part, remanded to afford him VA examinations to determine the severity of his service-connected allergic rhinitis and right and left knee disabilities, to include compliance with the requirements in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). In February 2020, the Veteran was afforded VA examinations that reflected the current severity of his service-connected allergic rhinitis and right and left knee disabilities. Notably, the February 2020 VA knee examination report reflects that the examiner provided sufficient findings that complied with the requirements in Correia and Sharp. Accordingly, the February 2020 VA examinations are sufficient for evaluation purposes, as the examiners rendered findings responsive to the rating criteria. See 38 C.F.R. § 4.2. Therefore, the agency of original jurisdiction (AOJ) complied with the Board’s remand instructions, with respect to the increased rating claims on appeals. Stegall v. West, 11 Vet. App. 268, 271 (1998). In a February 2020 rating decision, the DRO granted service connection for eczema, which was previously on appeal. The claim was previously adjudicated as service connection for a skin disability, which included diagnoses other than eczema, such as cutaneous T-cell lymphoma (CTCL). See Board remand (April 2019). Therefore, the grant of service connection for eczema does not represent a full grant of the benefit sought and the claim of service connection for a skin disability has been recharacterized accordingly. Also, in the February 2020 rating decision, the DRO granted service connection for chronic nasal sinusitis, which was previously on appeal. The Veteran has not appealed the rating or effective date assigned to that disability and, thus, this matter is not on appeal. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Initial and Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). As to the increased rating claims for the right and left knee disabilities, compensation has already been established and the increase in the disability ratings are at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). With respect to the initial rating claim for allergic rhinitis, that issue arose from an initial assigned rating and consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). 1. A rating in excess of 10 percent for a right knee disability. 2. A rating in excess of 10 percent for a left knee disability. The Veteran’s right knee disability is rated as 10 percent disabling under 38 C.F.R. § 4.71a, DCs 5003-5260. The Veteran’s left knee disability is rated as 10 percent disabling under 38 C.F.R. § 4.71a, DCs 5010-5260. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, DC 5003. Under DC 5260, limitation of flexion of the leg is rated as a noncompensable when flexion is limited to 60 degrees; a 10 percent rating is warranted when flexion is limited to 45 degrees; a 20 percent rating is warranted when flexion is limited to 30 degrees; and a 30 percent rating is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. VA’s General Counsel has held that separate ratings can be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Under DC 5261, limitation of extension of the leg, is rated as noncompensable when extension is limited to 5 degrees; a 10 percent rating is warranted when extension is limited to 10 degrees; a 20 percent rating is warranted when extension is limited to 15 degrees; a 30 percent rating is warranted when extension is limited to 20 degrees; a 40 percent rating is warranted when extension is limited to 30 degrees; and a 50 percent rating is warranted when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Under DC 5257, a 10 percent rating is warranted for slight 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, DC 5257. Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Moreover, the joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. Further, in claims for higher ratings for musculoskeletal disabilities, where a veteran has a noncompensable rating and complaints of pain on motion, the veteran may be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). In Petitti v. McDonald, 27 Vet. App. 415 (2015), the Court held that under 38 C.F.R. § 4.59, “the trigger for a minimum disability rating is an actually painful, unstable, or malaligned joint,” and it explained that 38 C.F.R. § 4.59 speaks to both painful motion of joints and actually painful joints. Id. at 425. Moreover, the Court held that 38 C.F.R. § 4.59 does not require “objective” evidence but can be satisfied with lay and other nonmedical evidence. Id. at 429. The provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Id. Moreover, the plain language of § 4.59 indicates that it is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable, or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is being evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016). Turning to the evidence, in August 2017, the Veteran filed increased rating claims for his right and left knee disabilities. In November 2016, the Veteran was afforded a VA examination. He reported bilateral knee pain, instability, swelling, and severe flare up knee symptoms. He indicated that he was unable to walk, run, squat, kneel, or stand for “any length of time.” He stated that he wore a knee brace for ambulation. The examiner noted that the Veteran arrived to the examination in a wheelchair. Upon physical examination, range of motion of the knees were recorded as forward flexion to 100 degrees with pain and extension was to 0 degrees with pain. He was able to perform repetitive-use testing without additional loss of function or range of motion. The November 2016 VA examiner was unable to opine as to whether pain, weakness, fatigability, incoordination, and flare-up symptoms would significantly limit the Veteran’s functional ability with repeated use over a period of time. The November 2016 examiner explained that the effects from flare up symptoms and repetitive motion vary from “incident to incident in intensity and severity”; and thus, the examiner was unable to determine the degree of loss of motion or functional impairment without resorting to mere speculation. The examiner indicated that the Veteran had pain with weight bearing. There was no ankylosis of either knee. Joint stability testing, bilaterally, was normal. There was no history of recurrent subluxation, lateral instability, or effusion of either knee. The examiner noted that the Veteran had crepitus during range of motion testing. The examiner concluded that the Veteran’s bilateral knee disability impacted his ability to work. The examiner explained that the Veteran would be unable perform occupational tasks that require standing, walking, or sitting. A November 2016 VA treatment record shows that there was no joint effusion upon physical examination. Range of motion of the knees were recorded as forward flexion to 120 degrees with pain and extension was 0 degrees with pain. The examiner indicated that there was mild crepitus during passive range of motion testing and that joint stability testing was normal. In January 2019, the Veteran was afforded a knee examination. The January 2019 VA examination did not comply with the requirements in Correia and Sharp; therefore, the range of motion testing during the January 2019 examination is inadequate and will not be used for evaluation purposes or discussed further. The portions of the examination that recorded the Veteran’s knee symptoms and test results, other than range of motion are adequate, as they provide sufficient details for evaluation purposes. During the January 2019 VA examination, the Veteran reported bilateral knee pain. He stated that he had had bilateral knee pain with prolonged standing or ambulation. He stated that he wore a right knee brace for ambulation. He denied flare ups of knee symptoms. There was no pain with weight bearing or nonweight-bearing. There was no muscle atrophy or ankylosis of either knee. Muscle strength and joint stability testing were normal. The examiner indicated that there was no history of recurrent subluxation, lateral instability, or effusion. The examiner indicated that an August 2017 left knee x-ray of showed small suprapatellar effusion. There was no crepitus or localized tenderness or pain of the either joint. The examiner indicated that the Veteran had a meniscus condition, as he had a bilateral knee meniscotomy in 2017. The examiner concluded that the Veteran’s bilateral knee disability impacted his ability to work, as he had knee pain with prolonged standing and ambulation. During the January 2019 Board hearing, the Veteran reported bilateral knee pain, stiffness, limitation of motion, weakness, and instability or a giving away. The Veteran indicated that he fell on several occasions due to his bilateral knee disability. In February 2020 the Veteran was afforded a VA knee examination. He reported that he had functional loss and/or functional impairment of the knees, as he had constant, chronic pain. He also stated that he had severe knee flare ups daily or twice a month that lasted for hours. He stated that during knee flare ups, he had difficulty walking and standing, did not want to move, and had to crawl to the bathroom. He indicated that he required a cane for ambulation. The examiner indicated that the Veteran’s flare ups were precipitated by running, lifting, standing, and walking. Upon physical examination, range of motion of the knees were recorded as forward flexion to 100 degrees with pain and extension was to 0 degrees with pain. The Veteran was able to perform repetitive-use testing without additional loss of function or range of motion. The examiner indicated that pain, weakness, fatigability, incoordination, and flare up symptoms, significantly limited the Veteran’s functional ability with repeated use over a period of time. There was no pain with weight bearing or non-weight bearing. The Veteran had pain on passive range of motion testing of the knees. The examiner estimated that the right and left knee flexion would be limited to 95 degrees and that extension would be limited to 0 degrees, during periods of pain, weakness, and flare ups. There was no muscle atrophy or ankylosis of either knee. Muscle strength and joint stability testing were normal. The examiner indicated that there was no history of recurrent subluxation or lateral instability. There was no crepitus or localized tenderness or pain of the joint. The examiner indicated that there was recurrent bilateral knee effusion, as the Veteran had intermittent swelling in his knees; however, the examiner indicated that x-rays of the knees showed no soft tissue swelling or joint effusion. The examiner noted that the Veteran had a meniscus condition, as he had a bilateral knee meniscotomy in 2018. The examiner indicated that the Veteran had no current meniscus condition symptoms. The February 2020 examiner indicated that x-rays of the knees showed that there was no fracture, subluxation, or abnormal joints. The examiner found that the Veteran’s bilateral knee disability impacted his ability to work and that he had functional impairments due to his knees, as he had pain with prolonged walking, standing, kneeling, squatting, and repetitive stair climbing. Limitation of Flexion and Limitation of Extension For the following reasons, ratings higher than 10 percent under DC 5260 for lamination of knee flexion, and/or compensable ratings under DC 5261 for limitation of knee extension, are not warranted for the right and left knee disabilities at any time throughout the appeal period. During the appeal period, the Veteran reported bilateral knee pain, severe flare ups, stiffness, and functional impairment. The Veteran is competent to report the symptoms associated with his bilateral knee disability and the extent of his impairment during flare ups of symptoms and following repetitive use, and the Board has no reason to challenge the credibility of his contentions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, the preponderance of the evidence supports the conclusion that the Veteran’s bilateral knee symptoms have most closely approximated the criteria for a 10 percent rating under DC 5260 throughout the appeal period. The evidence of record shows that the Veteran’s right and left knee flexion was limited, at worst, to 100 degrees with pain and that his right and left knee extension was limited, at worst, to 0 degrees, including on repetition. Furthermore, the evidence reflects that the Veteran reported that he had severe bilateral knee flare ups and that during flare ups he had difficulty walking and standing, he did not want to move, and had to crawl to the bathroom. To this extent, the February 2020 VA examiner considered the Veteran’s reports of severe flare ups and other functional impairment and estimated that the Veteran’s right and left knee flexion would be limited to 95 degrees and that extension would be limited to 0 degrees, during periods of pain, weakness, and flare-ups. Thus, the Veteran’s bilateral knee flexion would be limited, at worst, to 95 degrees and that his knee extension would be limited, at worst, to 0 degrees, when considering painful motion, severe flare ups, and other functional impairment. According, the preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran’s bilateral knee symptoms have not been shown to have been so disabling to actually or effectively result in limitation of knee flexion more nearly approximating 30 degrees or limitation of knee extension more nearly approximating 10 degrees, which are the requirements for a 20 percent rating for limitation of knee flexion under DC 5260 and a compensable (10 percent) rating for limitation of knee extension under DC 5261, respectively. The Veteran’s current 10 percent ratings under DC 5260 compensates him for his limited range of motion, flare ups, and functional loss. 38 C.F.R. §§ 4.40, 4.59; Burton, 25 Vet. App. at 5. As the preponderance of the evidence is against higher or separate ratings, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Instability During the November 2016 VA examination, the Veteran reported bilateral knee instability. During the January 2019 Board hearing, the Veteran indicated that he had bilateral knee instability or giving way. Furthermore, throughout the appeal period, the Veteran required a brace for ambulation and a wheelchair during the November 2016 examination. The Veteran is competent to report observable symptoms of his bilateral knee disability, such as instability. See Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The Veteran’s reports regarding his instability are credible, as his statements have remained consistent throughout the appeal period. Therefore, in light of the Veteran’s competent and credible reports of bilateral knee instability and that he required a brace for ambulation, separate 10 percent ratings under DC 5257 for slight recurrent subluxation or lateral instability are warranted. See English v. Wilkie, 30 Vet. App. 347, 349 (2018). Ratings higher than 10 percent for bilateral knee instability are not warranted, as there was no history of subluxation or lateral instability of either joint. Also, stability testing was normal throughout the appeal period. Therefore, the Veteran’s bilateral knee instability did not more nearly approximate moderate instability. Other DCs pertaining to the knee include DC 5258 (dislocation of the semilunar cartilage). Under DC 5258, a 20 percent is warranted for a dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. During, the January 2019 examination, the examiner indicated that an August 2017 left knee x-ray of showed small suprapatellar effusion. The February 2020 VA examiner found that the Veteran had joint effusion, as he had intermittent swelling in his knees; however, the examiner also indicated that x-rays of the knees showed no soft tissue swelling or joint effusion. In any event, although there was evidence of pain and effusion, the Veteran did not have a dislocation of the semilunar cartilage or frequent episodes of locking. Therefore, a separate or a higher rating under DC 5258 is not warranted. Throughout the appeal period, there was no evidence of knee ankylosis, impairment of the tibia or fibula, or genu recurvatum. Therefore, separate/higher ratings are not warranted under DCs 5256, 5259, 5262, or 5263 at any time during the claim period. Allergic Rhinitis In a May 2016 rating decision, the RO granted service connection for allergic rhinitis and assigned a noncompensable rating under 38 C.F.R. § 4.97, DC 6522, effective August 31, 2015, the date of the claim of service connection. The Veteran timely disagreed with the initial rating assigned. In an August 2018 rating decision, the DRO increased the rating for allergic rhinitis to a 10 percent rating, effective August 7, 2017, date of a VA examination that showed that the Veteran had greater than 50 percent obstruction of nasal passages on both sides. Under DC 6522, allergic or vasomotor rhinitis, a 10 percent rating is warranted when there are no polyps but with greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. A 30 percent rating is warranted when polyps are present. 38 C.F.R. § 4.97. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31. 1. An initial compensable rating for rating for allergic rhinitis, prior to August 7, 2017. In February 2016, the Veteran was afforded a VA examination. The Veteran reported sharp pain and pressure around his eye, frequent sinus congestion, and rhinorrhea. The VA examiner noted that a computed tomography showed mild mucosal changes in the left maxillary sinus and that the remainder of the paranasal sinuses and bones were normal. The examiner found that the Veteran did not have greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. The examiner also indicated that there were no nasal polyps. VA treatment records prior to August 7, 2017, show that the Veteran required nasal spray to treat his allergic rhinitis. For the following reasons, a compensable rating for rating for allergic rhinitis, prior to August 7, 2017, under DC 6522 is not warranted. The evidence does not demonstrate that the Veteran had greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side, or that he had nasal polyps associated with his allergic rhinitis. See 38 C.F.R. § 4.97. To any extent that the Veteran contends that he had greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side, or that he had nasal polyps associated with his allergic rhinitis, he is not competent to evaluate the severity of his allergic rhinitis or identify the percentage of obstruction of nasal passage. The precise degree of obstruction of a nasal passage is an internal, non-observable process which is of the type that the courts have found to be beyond the competence of lay witnesses. See Clemons v. Shinseki, 23 Vet. App. 1, 6. Therefore, the Veteran statements in that regard are not competent. The preponderance of the evidence is against a compensable rating for allergic rhinitis under DC 6522, prior to August 7, 2017, the benefit-of-the-doubt doctrine is not for application, and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 2. A rating higher than 10 percent for allergic rhinitis, since August 7, 2017. In an August 2017 VA examination, the VA examiner found that the Veteran had 50 percent obstruction of the nasal passages on both sides. The examiner indicated that the Veteran did not have nasal polys. In a February 2020 VA examination, the examiner diagnosed allergic rhinitis and indicated that the Veteran did not have nasal polys. VA treatment records show that the Veteran required nasal spray to treat his allergic rhinitis. For the following reason, a rating higher than 10 percent for allergic rhinitis, since August 7, 2017, is not warranted. The evidence does not demonstrate the presence of nasal polyps. To the extent that the Veteran contends that he has had nasal polys associated with his allergic rhinitis, nasal polys is not an observable symptom, as it requires medical testing and expertise that is outside the realm of common knowledge of a lay person. Therefore, the Veteran’s statements that he has had nasal polys associated with his allergic rhinitis is not competent. Notably, throughout the appeal period, the Veteran’s disability has been diagnosed as allergic rhinitis. Allergic rhinitis is rated under 38 C.F.R. § 4.97, DC 6522. A disability may not be rated by analogy under another code, when a condition is already specifically listed in the rating schedule. See Copeland v. McDonald, 27 Vet. App. 333, 338 (2015). The preponderance of the evidence is against a rating in excess of a 10 percent rating for rating for allergic rhinitis under DC 6522, since August 7, 2017, the benefit-of-the-doubt doctrine is not for application, and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. New and Material Evidence Generally, a claim that has been denied in a final unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). An exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA will reopen the claim and review it on the merits. The implementing regulation also provides that new and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim that was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means 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 previously of record 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 evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held, however, that evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented. Anglin v. West, 203 F.3d 1343, 1347 (2000). In deciding whether new and material evidence has been received, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Regardless of whether the RO determined new and material evidence had been submitted, the Board must address the issue of the receipt of new and material evidence in the first instance because it determines the Board’s jurisdiction to reach the underlying claims and to adjudicate the claims de novo. See Jackson v. Principi, 265 F.3d 1366, 1369 (2001) (the Board has a jurisdictional responsibility to consider whether it was proper for a claim to be reopened, regardless of whether the previous action denying the claim was appealed to the Board). 1. Whether new and material evidence has been received to reopen the previously denied claim of service connection for a dental disorder. In an April 2013 rating decision, the RO denied service connection for a dental disorder, on the basis that there was no dental disorder that occurred in or was caused by service. Later that month, in an April 2013 notification letter, the Veteran received notice of the April 2013 rating decision. He did not appeal that decision and new and material evidence was not associated with the record within one year of its issuance. Accordingly, the October 2013 rating decision is final. See 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103. The relevant evidence at the time of the April 2013 rating decision, included the Veteran’s statements (which indicated that he had dental work performed on his teeth during service) and service treatment records (STRs) that revealed in May 1977, he had a decayed tooth that required treatment. The Board notes that within one year of the April 2013 rating decision, in October 2013, the Veteran’s spouse submitted a statement indicating that during the Veteran’s service, he had a fall, injured his mouth and teeth, and that he had a severe infection. The October 2013 statement is not considered new and material evidence, as the Veteran’s spouse’s statement was duplicative of the evidence of record. To this extent, the Veteran’s spouse’s statement is redundant of the Veteran’s statements concerning his in-service injury that resulted in dental work. Additionally, the Veteran contends that there were outstanding STRs. In April 2019, the Board remanded the appeal to obtain any inpatient clinical records from a hospital in Pearl Harbor; a response from the hospital in Pearl Harbor indicated that there were no record or admissions for the Veteran from January 1979 to September 1980. See letter from Triple Army Medical Hospital (June 2019). Therefore, consideration of the provisions of 38 C.F.R. § 3.156(c), relating to the receipt of relevant official service department records, is therefore not required. Since the April 2013 rating decision, the relevant evidence includes the Veteran’s August 2015 claim to reopen his previously denied claim of service connection for a dental disorder, an August 2015 statement, treatment records, and the January 2019 Board hearing transcript. Specifically, in an August 2015 statement, the Veteran reported that during service, he fell, had a mouth and teeth injury that caused a severe infection, and was airlifted for treatment. During the January 2019 Board hearing, the Veteran testified that he has had an uneven tooth since service. The Veteran’s VA treatment records note an assessment of “dental insufficiency”. See, e.g. VA treatment record May 2015. The new evidence, the Veteran’s testimony that he has had an uneven tooth since service and the VA treatment records that note a dental insufficiency, was not previously considered in the final prior April 2013 rating decision and relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim. See Shade, 24 Vet. App. at 117. Therefore, the criteria for reopening the claim for service connection for a dental disorder are met. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first 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). The Veteran asserts that his acquired psychiatric disorder is due to his military service and that he has had symptoms of a psychiatric disorder in and since service. See, e.g., Board hearing transcript (January 2019). The Veteran claims that his psychiatric disorder is the result an in-service fall off a truck and hitting his head, and in-service harassment. See Board hearing transcript (January 2019); VA examination report (January 2020). Although STRs do not appear to indicate that the Veteran sustained a head injury, his STRs reveal that he fell from a truck in December 1979. Furthermore, STRs document that the Veteran sought in-service treatment for depression, anxiety, suicidal ideation, and homicidal ideation. See, e.g., STR June 1980. Moreover, in the Veteran’s August 1980 separation report, the examiner noted that the Veteran was treated at a hospital in June 1980 because he was “emotionally upset.” The Veteran’s DD Form 214 reflects that he was discharged under honorable conditions; the narrative reason for separation states “unsuitability-apathy, defective attuite or inability to expend effort constructively.” One year following service, in December 1981, the Veteran submitted a claim of service connection for nervous condition. In a February 2015 VA treatment record, the Veteran reported that his onset of depression began around thirty plus years ago and that he has had mental health treatment since 1980. In an April 2015 assessment summary, a private psychologist indicated that he interviewed the Veteran, documented his history and diagnosed anxiety and depressive disorders. The private psychologist found that the Veteran’s acquired psychiatric disorder were related to his military service. The private psychologist explained that during the Veteran’s service, he was admitted to a hospital for psychiatric treatment and that he was discharged from service because he was found unfit. The private psychologist indicated that the Veteran had suffered from psychiatric symptoms since service, as he had periods of homelessness and irritability. The private psychologist also indicated that the Veteran’s depression was a result of his military experiences. The April 2015 opinion is entitled to significant probative weight, as the private psychologist explained the reasons for his conclusions based on an accurate characterization of the evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). In sum, the evidence shows a current acquired psychiatric disorder. The Veteran reports that he has had psychiatric symptoms in and since service. His reports are supported by the evidence of record, as the Veteran filed a service connection claim for a nervous condition one year following his separation from service. Furthermore, in February 2015, the Veteran reported to his treatment provider that his depression symptoms began 30-plus years ago and that he has had mental health treatment since 1980. See Fed. R. Evid. 803(4) (noting that statements made to physicians for the purposes of diagnosis and treatment are exceptionally trustworthy and not excluded by the hearsay rule because the declarant has a strong motive to tell the truth in order to receive proper care); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (“[R]ecourse to the [Federal] Rules [of Evidence] is appropriate where they will assist in the articulation of the Board’s reasons”)). Moreover, a private psychologist found that the Veteran’s acquired psychiatric disorder was related to his military service and that he has had symptoms since service. Notably, the evidence of record contains negative nexus opinions between the Veteran’s military service and acquired psychiatric disorders. See, e.g., VA opinion (January 2020). To this extent, the negative nexus opinions are afforded little probative value if any, as the opinions did not consider the Veteran’s in-service psychiatric symptoms and his reports of psychiatric symptoms since service. Accordingly, service connection for an acquired psychiatric disorder, diagnosed as a depressive disorder, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. To the extent that other psychiatric disorders have been diagnosed, there is no indication that there are distinct psychiatric symptoms attributable to such disorders, and all psychiatric symptoms will therefore be attributed to the now service-connected depressive disorder. See Howell v. Nicholson, 19 Vet. App. 535, 540 (2006); Mittleider v. West, 11 Vet. App. 181, 182 (1998) (VA must apply the benefit of the doubt doctrine and attribute the inseparable effects of a disability to the claimant’s service-connected disability). Consequently, consideration of whether other psychiatric disorders, excluding PTSD, are related to the Veteran’s military service is unnecessary. REASONS FOR REMAND 1. The issue of service connection for a right hand disability is remanded. 2. The issue of service connection for a left hand disability is remanded. 3. The issue of service connection for disorder of the right upper extremity is remanded. In April 2019, the Board remanded the claims to obtain VA opinions regarding the nature and etiology of any current disorders of the bilateral hands and/or right upper extremity pursuant to Saunders v. Wilkie, 886 F.3d 1356, 1365-68 (Fed. Cir. 2018), as a February 2016 VA examiner found no current diagnoses. In an October 2019 hand and finger conditions disability benefits questionnaire (DBQ), a private examiner diagnosed bilateral carpal tunnel syndrome and ulnar neuropathy based on a nerve condition study; no etiology opinion was provided. In January 2020, the Veteran was afforded a VA hand and fingers examination. The VA examiner indicated that there was no left hand, right hand, or right upper extremity disability due to lack of pathology. The examiner explained that the x-rays results were negative of a diagnosis. In sum, the January 2020 VA examiner did not address the diagnoses found in the October 2019 DBQ and there is no etiological opinion as to the diagnosed bilateral carpal tunnel syndrome and ulnar neuropathy in the right upper extremity. Therefore, a remand is necessary to obtain a VA opinion to address the etiology the of the Veteran’s bilateral carpal tunnel syndrome and ulnar neuropathy in the right upper extremity. 4. The issue of service connection for PTSD is remanded. The Veteran asserts that his PTSD is due to an in-service fall off a truck and hitting his head and in-service harassment. See, e.g., Board hearing transcript (January 2019); VA examination report (January 2020). In April 2019, the Board remanded the appeal to obtain any inpatient clinical records from a hospital in Pearl Harbor; a response from the hospital in Pearl Harbor indicated that there were no record or admissions for the Veteran from January 1979 to September 1980. See letter from Triple Army Medical Hospital (June 2019). Although STRs do not appear to indicate that the Veteran sustained a head injury, his STRs reveal that he fell from a truck in December 1970. Furthermore, STRs document that the Veteran sought in-service treatment for depression, anxiety, suicidal ideation, and homicidal ideation. See, e.g., STR June 1980. The Veteran has been afforded a VA examination to determine the nature and etiology of any acquired psychiatric disorder. In a January 2020 VA examination, the VA examiner indicated that the Veteran did not meet the criteria for PTSD. To this extent, although the January 2020 VA examiner found that the Veteran did not have a current diagnosis of PTSD, the Veteran’s treatment records include an assessment of PTSD. See, e.g., VA treatment record (July 2015). Therefore, upon remand, a VA opinion should be obtained to determine the etiology of the Veteran’s PTSD. 5. The issue of service connection for residuals of a TBI is remanded. The Veteran contends that during service, he fell off a truck, sustained a head injury and or a TBI. See, e.g., Veteran’s statement (August 2015). The Veteran has been afforded VA examinations to determine whether he had residuals of a TBI. VA examiners have found that the Veteran had not suffered a TBI or had residuals of a TBI. See VA examination (February 2016); (January 2020). Notably, in the February 2016 VA TBI examination report the examiner indicated that neuropsychological testing had not performed. Furthermore, in the January 2020 PTSD examination, the examiner noted that the Veteran was an “inconsistent historian that needed redirection several times during the” examination and suggested that he would benefit from a “comprehensive neuropsychological evaluation due to complexity of his presentation and further diagnostic clarification.” In sum, the February 2016 VA TBI examination report reflects that neuropsychological testing had not performed and the January 2020 examiner suggested that neuropsychological evaluation should be performed. Therefore, upon remand, the Veteran should be scheduled for a neuropsychological evaluation and an opinion should be obtained to determine whether the Veteran has or had TBI residuals from falling off a truck in service. 6. The issue of service connection for a dental disorder is remanded. The Veteran seeks service connection for a dental disorder. See, e.g., Board hearing transcript (January 2019). The Veteran claims that during service, he had dental work performed and had an infection. A May 1977 STR shows that the Veteran had a decayed tooth that required treatment. During the January 2019 Board hearing, the Veteran testified that he has had an uneven tooth since service. The Veteran’s VA treatment records note an assessment of “dental insufficiency”. See, e.g. VA treatment record May 2015. The Veteran has not been afforded a VA dental examination. Therefore, upon remand, the Veteran should be afforded a dental examination to determine the nature and etiology of his dental disorder. 7. The issue of service connection for a skin disability, other than eczema, is remanded. Following the April 2019 Board remand and requested development, the DRO granted service connection for eczema. The grant of service connection for eczema did not represent a full grant of the benefit sought, as the claim was previously adjudicated as service connection for a skin disability, which included diagnoses other than eczema, such as CTCL. The February 2020 Supplemental Statement of the Case (SSOC) did not adjudicate the issue of service connection for a skin disability, other than eczema. Accordingly, upon remand a SSOC should be issued regarding the issue of service connection for a skin disability, other than eczema. The matters are REMANDED for the following action: 1. Refer the claims file to a physician for an opinion as to the claims of service connection for a right hand disability, left hand disability, and a disorder in the right upper extremity. The Veteran does not need to be examined, unless the physician determines it is necessary. The physician should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed bilateral carpal tunnel syndrome and ulnar neuropathy in the right upper extremity had its/their onset in service or is/are otherwise related to service, to include as due to working with heavy artillery during service. The physician must provide a rationale for each opinion. 2. Refer the claims file to a psychiatrist or psychologist to determine the etiology of the Veteran’s PTSD. The Veteran does not need to be examined unless a psychiatrist or psychologist determines it is necessary. The psychiatrist or psychologist should determine whether the Veteran’s meets the criteria for PTSD during the appeal period and identify the specific stressor(s) underlying any PTSD diagnosis and comment upon the link between the current symptomatology and the Veteran’s stressor(s). The psychiatrist or psychologist must provide a rationale for the opinion. 3. Schedule the Veteran for a neuropsychological evaluation regarding his claim of service connection for residuals of TBI. A VA physician should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran has current residuals from falling off a truck in service, in December 1970. The physician must provide a rationale for the opinion. 4. Schedule the Veteran for a dental examination. The examiner should identify whether the Veteran has or had a dental disorder, since the date of his service connection claim in August 2015. Then, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s dental disorder was caused by his in-service dental trauma. The examiner must provide a rationale for the opinion. 5. Readjudicate the issues on appeal, to include issuing a SSOC regarding the issue of service connection for a skin disability, other than eczema. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs 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.