Citation Nr: 20049335 Decision Date: 07/23/20 Archive Date: 07/23/20 DOCKET NO. 11-31 409 DATE: July 23, 2020 ORDER Service connection for erectile dysfunction to include as secondary to service-connected psychiatric disability is denied. Service connection for a left knee disability is denied. Service connection for a right knee disability is denied. Service connection for a disability manifested as difficulty with breathing as secondary to service-connected psychiatric disability is granted. Service connection for a disability manifested as left-hand numbness, to include as a result of undiagnosed illness or other qualifying, chronic disability pursuant to 38 U.S.C. § 1117, is denied. Service connection for a disability manifested as right-hand numbness, to include as a result of undiagnosed illness or other qualifying, chronic disability pursuant to 38 U.S.C. § 1117, is denied. Entitlement to an initial rating in excess of 30 percent for a disability manifested by heartburn as secondary to service-connected psychiatric disability is denied. Entitlement to an initial rating of 70 percent for post-traumatic stress disorder (PTSD) with depression, panic disorder without agoraphobia, and alcohol abuse for the period beginning August 13, 2009 is granted. Entitlement to an initial rating in excess of 70 percent for PTSD with depression, panic disorder without agoraphobia, and alcohol abuse for the period beginning August 13, 2009 is denied. Entitlement to the extension of a convalescent rating under 38 C.F.R. § 4.30 after July 31, 2013 for right shoulder impingement status post arthroscopic subacromial decompression is denied. Entitlement to an effective date earlier than August 13, 2009 for a grant of service connection for right shoulder impingement status post arthroscopic subacromial decompression is denied. Entitlement to an effective date earlier than August 13, 2009 for a grant of service connection for limitation of extension due to lateral epicondylitis of the right elbow is denied. Entitlement to an effective date earlier than August 13, 2009 for a grant of service connection for impairment of supination and pronation due to lateral epicondylitis of the right elbow is denied. Entitlement to special monthly compensation (SMC) prior to June 17, 2013 based on being housebound is denied. Entitlement to SMC based on being housebound after July 31, 2013 is denied. REMANDED The claim for a rating in excess of 10 percent for residuals of a right ankle fracture with degenerative joint disease is remanded. The claim for an initial rating in excess of 20 percent for right shoulder impingement status post arthroscopic subacromial decompression prior to June 17, 2013 is remanded. The claim for an initial rating in excess of 20 percent for right shoulder impingement status post arthroscopic subacromial decompression for the period beginning August 1, 2013 is remanded. The claim for an initial compensable rating for limitation of extension due to lateral epicondylitis of the right elbow is remanded. The claim for an initial rating in excess of 10 percent for impairment of supination and pronation due to lateral epicondylitis of the right elbow is remanded. The claim for service connection for sleep apnea to include as secondary to service-connected psychiatric disability is remanded. The claim for a total disability rating for compensation based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The most probative evidence is against a conclusion that erectile dysfunction was incurred in service or is proximately due to or a result of service-connected psychiatric disability, to include with consideration of aggravation. 2. The most probative evidence is against a conclusion that the Veteran has a left or right knee disability that was incurred in service. 3. There is competent evidence of record linking difficulty with breathing to psychiatric difficulties. 4. The most probative evidence of record weighs against a conclusion that the Veteran has a disability manifested as left or right hand numbness that was due to service, to include as a result of an undiagnosed illness or other qualifying, chronic disability based on his presence in the Southwest Asia theater of operations. 5. The evidence demonstrates a direct linkage of the Veteran’s difficulty with breathing to psychiatric problems. 6. For the period prior beginning August 13, 2009, it is at least as likely as not that the service-connected psychiatric disorder resulted in occupational and social impairment with deficiencies in most areas and an inability to establish and maintain effective relationships. 7. For the period beginning August 13, 2009, the service-connected psychiatric disorder has not resulted in total social and occupational impairment. 8. For the period after July 31, 2013, the service-connected right shoulder impingement status post arthroscopic subacromial decompression did not necessitate at least one month of convalescence; surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more; application of a body cast; the necessity for house confinement, the necessity for continued use of a wheelchair or crutches; or immobilization by cast, without surgery, of one major joint or more. 9. Review of the record dated prior to August 13, 2009, reveals no document that may be reasonably construed as a claim for service connection for a right shoulder or right elbow disability. 10. Prior to June 17, 2013 and after July 31, 2013, the Veteran was not substantially confined to his home as a result of service-connected disabilities, nor did he have a single service-connected disability rated as 100 percent disabling with additional service-connected disability rated as 60 percent or more. CONCLUSIONS OF LAW 1. The criteria for service connection for erectile dysfunction to include as secondary to service-connected psychiatric disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2019). 2. The criteria for service connection for a left or right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2019). 3. The criteria for service connection for breathing problems as secondary to service-connected psychiatric disability have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2019). 4. The criteria for service connection for a disability manifested as left or right-hand numbness to include as a result of an undiagnosed illness or other qualifying, chronic disability due to the Veteran’s presence in the Southwest Asia theater of operations have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.317 (2019). 5. The criteria for an initial rating in excess of 30 percent for a disability manifested by heartburn as secondary to service-connected psychiatric disability have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.114, Diagnostic Code (DC) 7346. 6. Resolving all reasonable doubt in favor of the Veteran, the criteria for a 70 percent rating for PTSD with depression, panic disorder without agoraphobia, and alcohol abuse for the period beginning August 13, 2009 have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107, 5110(a), (2012); 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.1, 4.2, 4.3, 4.7, 4.130 DCs 9411, 9434 (2019). 7. The criteria for a rating in excess of 70 percent rating for PTSD with depression, panic disorder without agoraphobia, and alcohol abuse for the period beginning August 13, 2009 have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107, 5110(a), (2012); 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.1, 4.2, 4.3, 4.7, 4.130 DCs 9411, 9434 (2019). 8. The criteria for an extension of a convalescent rating under 38 C.F.R. § 4.30 after July 31, 2013 for right shoulder impingement status post arthroscopic subacromial decompression have not been met. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.30 (2019). 9. The legal requirements for an effective date prior to August 13, 2009, for the grants of service connection for right shoulder and right elbow disorders have not been met. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400(b)(2) (2019). 10. The criteria for SMC based on being housebound prior to June 17, 2013, and after July 31, 2013, are not met. 38 U.S.C. § 1114(s) (West 2012); 38 C.F.R. §§ 3.350(i) (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1984 to March 1988 and from August 1988 to September 1992. Summarizing the procedural background of the instant case, a July 2015 Board of Veterans’ Appeals (Board), in pertinent part, denied a claim for service connection for erectile dysfunction to include as secondary to service connected psychiatric disability and remanded claims for service connection for right shoulder, right elbow, left knee, and right knee disabilities; claims for service connection for a disability manifested as difficulty with breathing and left and right hand numbness to include as a result of undiagnosed illness or other qualifying, chronic disability pursuant to 38 U.S.C. § 1117; a claim for an initial rating in excess of 30 percent for a disability manifested by heartburn as secondary to service connected psychiatric disability; claims for an initial rating in excess of 30 percent for PTSD with depression, panic disorder without agoraphobia, and alcohol abuse prior to April 22, 2011 and in excess of 70 percent from April 22, 2011; and a claim for a rating in excess of 10 percent for residuals of a right ankle fracture. The Veteran appealed the denial of service connection for erectile dysfunction to include as secondary to service connected psychiatric disability by the July 2015 Board decision to the U.S. Court of Appeals for Veterans Claims (Court), and that portion of the July 2015 Board was vacated by a March 2016 Court order pursuant to a March 2016 Joint Motion for Partial Remand (JMPR). The Board remanded the case in July 2016 for development pursuant to the JMPR, and the requested development with respect to the claim for service connection for erectile dysfunction to include as secondary to service-connected psychiatric disability has been completed. The development with respect to the following claims remanded by the Board in July 2015 has also been accomplished: entitlement to service connection left and right knee disabilities; entitlement to service connection for a disability manifested as difficulty with breathing and left and right hand numbness to include as a result of undiagnosed illness or other qualifying, chronic disability pursuant to 38 U.S.C. § 1117; entitlement to an initial rating in excess of 30 percent for a disability manifested by heartburn as secondary to service connected psychiatric disability is denied; and entitlement to increased compensation for PTSD with depression, panic disorder without agoraphobia, and alcohol abuse. The claims for service connection for right shoulder and right elbow disabilities remanded by the Board in July 2015 were granted by way of a November 2018 rating decision which granted service connection for right shoulder impingement status post arthroscopic subacromial decompression, limitation of extension due to lateral epicondylitis of the right elbow, and impairment of supination and pronation due to lateral epicondylitis of the right elbow. Following an October 2019 statement of the case (SOC) that denied claims for an extension of a convalescent rating under 38 C.F.R. § 4.30 after July 31, 2013 for right shoulder impingement status post arthroscopic subacromial decompression; entitlement to an effective date earlier than August 13, 2009 for the grants of service connection for right shoulder impingement, limitation of extension due to lateral epicondylitis or the right elbow, and impairment of supination and pronation due to lateral epicondylitis of the right elbow; entitlement to an effective date prior to June 17, 2013 for SMC based on being housebound; entitlement to SMC based on being housebound after July 31, 2013; entitlement to an initial rating in excess of 20 percent for right shoulder impingement status post arthroscopic subacromial decompression prior to June 17, 2013; entitlement to an initial rating in excess of 20 percent for right shoulder impingement status post arthroscopic subacromial decompression for the period beginning August 1, 2013; entitlement to an initial compensable rating for limitation of extension due to lateral epicondylitis of the right elbow and entitlement to an initial rating in excess of 10 percent for impairment of supination and pronation due to lateral epicondylitis of the right elbow, a timely appeal to the Board with respect to these matters was perfected by way of a December 2019 substantive appeal. Finally, the claim for service connection for sleep apnea to include as secondary to service-connected psychiatric disability is on appeal following the submission of a substantive appeal in January 2020 with respect to a December 2019 SOC addressing this issue. With respect to the duty to assist, the Veteran’s service treatment records (STRs) from his first period of active duty have been obtained. Attempts were made to obtain the STRs from the Veteran's second period of service, as documented in a December 2009 Formal Finding on the Unavailability of Service Records memorandum, but these efforts were not successful. The Veteran was notified by a November 2009 letter that VA had not been able to obtain the STRs from the second period of active service, and this letter asked him to submit any STRs from this period of service that he had in his possession. In cases such as this in which STRs are incomplete or unavailable, the Board’s obligation to explain its findings and conclusions, and to consider carefully the benefit-of-the-doubt rule, is heightened. See O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992). However, O’Hare does not raise a presumption that the missing medical records would, if they still existed, necessarily support the claim. Case law does not establish a heightened “benefit of the doubt,” only a heightened duty of the Board to consider the applicability of the benefit of the doubt, to assist the claimant in developing the claim, and to explain its decision when a Veteran’s medical records have been destroyed. See Ussery v. Brown, 8 Vet. App. 64 (1995). Similarly, the case law does not lower the legal standard for proving a claim for service connection, but rather increases the Board’s obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the appellant. Russo v. Brown, 9 Vet. App. 46 (1996). No additional STRs have been received since the Veteran was requested to provide any such he had in his possession, but voluminous post service VA and private treatment records, as well as statements by the Veteran, have been considered by the undersigned. As such, the undersigned finds that the duty to assist has been fulfilled with respect to the matters adjudicated below. I. Service Connection Claims A. Legal Criteria When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an “approximate balance of positive and negative evidence” in order to prevail. The Court has also stated, “It is clear that to deny a claim on its merits, the evidence must preponderate against the claim.” Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from 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). A disability which is proximately due to or the result of a service-connected disease shall be service connected. 38 C.F.R. § 3.310(a). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability has aggravated a nonservice-connected disability. 38 C.F.R. § 3.310(b). Service connection may also be granted for a disability due to a qualifying chronic disability of a Veteran, such as in the instant case, who served in the Southwest Asia Theater of Operations, provided that such disability became manifest during either active service in the Southwest Asia Theater of Operations or to a degree of 10 percent or more, under the appropriate diagnostic code of 38 C.F.R. Part 4 not later than December 31, 2016, and by history, physical examination, and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. 38 U.S.C.§ 1117; 38 C.F.R. § 3.317(a)(1). A chronic qualifying disability means a chronic disability resulting from an (A) undiagnosed illness; (B) the following medically unexplained chronic multi symptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi symptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i). For the purposes of this section the term medically unexplained chronic multi symptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: (1) fatigue, (2) unexplained rashes or other dermatological signs or symptoms, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs and symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, and (13) menstrual disorders. 38 C.F.R. § 3.317(b). B. Analysis 1. Erectile Dysfunction The STRs from the first period of service do not reflect any evidence of erectile dysfunction. After service, the record reflects an injury to the spine—for which the Veteran filed a claim for workers' compensation—sustained when the Veteran fell from a truck during the course of his employment in July 1997. Private clinical records dated in 1997 and 1998 reflect treatment for marked degenerative disc disease in the lumbar spine with radiculopathy to the lower extremities. Reports from treatment for sacroiliac pain in June 1998 noted that the symptoms included some erectile dysfunction over the prior month. The Veteran reported continuing erectile dysfunction to a private examiner in July 1998, and indicated at that time that he had been having these problems since the injury sustained in the course of his civilian employment in 1997. As such, the examiner concluded at that time that the Veteran's erectile problems were due to his work-related injury. Ultimately, the Veteran’s erectile dysfunction necessitated a penile implant. See e.g., April 28, 1999 private treatment report. A September 2010 VA examination addressing the claim for service connection for erectile dysfunction, which reflect review of the claims file (and additional reports not of record said by the examiner to indicate that the Veteran’s employer paid for the penile implant as part of his workers’ compensation claim following the 1997 work-related injury), resulted in the conclusion by the examiner that the Veteran's work-related spine injury was the primary cause of his erectile dysfunction, and that this condition was less likely as not caused by or the result of his “posttraumatic stress.” The examiner did note the Veteran’s report of mild erectile dysfunction “in the context of marital discord and alcohol use” prior to his spinal injury. As indicated, service connection for erectile dysfunction to include as secondary to service-connected psychiatric disability was denied by a July 2015 Board decision, and this denial was vacated by the Court in March 2016 pursuant to a JMPR entered in that month. The JMPR found fault with the fact that the September 2010 VA examination relied upon in the July 2015 Board decision did not address the matter of whether service-connected psychiatric disability aggravated his erectile dysfunction. The JMPR also noted that the September 2010 VA examiner did not address the matter of whether the mild erectile dysfunction that was said to have predated the workplace spinal injury suggested a cause for the Veteran’s erectile dysfunction that predated the spinal injury, to include his service connected psychiatric disability. As such, the July 2016 Board remand directed that addendum opinions be completed that addressed these concerns raised in the March 2016 JMPR. The opinions requested by the July 2016 Board remand were completed in September 2018, with the clinician concluding that it was less likely than not that the Veteran’s erectile dysfunction was proximately due to, the result of, or aggravated by service connected psychiatric disability either before or after the 1997 workplace spinal injury. The rationale for the opinions was as follows: The record clearly indicates that the erectile dysfunction became markedly worse following the spinal surgery where there was no ability to obtain any kind of erection. This then led to the surgery to place an inflatable penile implant. Inasmuch as workman’s compensation agreed to cover the penile implant surgery, recognizing that it was the spinal surgery that caused [the] inability to obtain any erection, it is abundantly clear that that the spinal surgery is the primary cause of his erectile no-function and it is less likely than not caused by, the result of or aggravated by his service-connected PTSD with secondary depression and panic disorder. There is otherwise no medical opinion linking erectile dysfunction to service connected psychiatric disability, or directly to service, and the undersigned finds the September 2018 opinion to be definitive as to the matter of whether the Veteran’s erectile dysfunction is proximately due to, the result of, or aggravated by his service connected psychiatric disability. To the extent the assertions of the Veteran or his attorney are advanced in an attempt to establish that the Veteran’s erectile dysfunction is due to service or his service-connected psychiatric disability, such complex medical matters are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As neither the Veteran nor his attorney are shown to have appropriate training and expertise, neither are competent to render a persuasive opinion as to such matters. While the Veteran is competent to describe lay observable symptoms associated with his erectile dysfunction since service, the undersigned finds the silent STRs for this condition and the lack of any objective post service evidence linking a current disability associated with erectile dysfunction to service to be more probative than the lay assertions made in connection with the claim for service connection for this disability, and that these facts weigh against a finding of continuity of relevant symptoms associated with this condition since service. In sum, the undersigned finds that the preponderance of the evidence is against the Veteran’s claim for service connection for erectile dysfunction, to include as secondary to his service-connected psychiatric disability. As such, this claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 2. Left and Right and Knee Disabilities The only pertinent STR documenting a knee disability is July 1984 STR reflecting a right knee strain. A VA examination addressing the claims for service connection for left and right knee disabilities conducted pursuant to the July 2015 Board remand was accomplished in April 2016. The conclusion following this examination—which was documented to have been preceded by a review of the claims file and consideration of the Veteran’s reports of knee pain from his first period of active duty coincident with parachute jumps and continuing knee pain after service—was that it was less likely as not that the Veteran had a left or right knee disability that was incurred in service. The rationale for this opinion was as follow: Service treatment records show a single visit for right knee strain on active duty. Veteran reports he made 40-50 jumps on active duty, yet he had no findings of posttraumatic degenerative joint disease on 2012 x-rays of the left and right knee, 20 years after completion of his second period of service. Veteran's enlistment weight was approximately 70-80 pounds less than his weight during the period from 2010 forward, as found in his VA records. His 2011 VA records from primary care physician Dr. Dietrich, Cheyenne VA, have a first report of knee pain of 2 months duration with no history of injury. I note that [the] Veteran’s varied employment after active duty involved activities such as getting in and out of large vehicles/railroad cars, walking on cement floors as a prison guard, and working in warehouse moving cases of Pepsi beverages. Significant knee acute injury or repetitive joint trauma leads to long-term complication of osteoarthritis (post-traumatic arthritis). (Ref: Buckwalter JA, Thomas TD: Joint injury, repair, and remodeling: roles in post-traumatic osteoarthritis. Clin. Orthop. Rela. Res. 2004, 423: 7-16.) Osteoarthritis risk increases with time from onset of injury, as well as with additional risk factors such as obesity. Up to 80% of patients develop cartilage degeneration within 5 years of injury/trauma that is visible on MRI, which can precede visible degenerative findings of osteoarthritis on x-ray images. (Ref: Gelber AC, Hochberg MC, Mead LA, Wang NY, Wigley FM, Klag MJ: Joint injury in young adults and risk for subsequent knee and hip osteoarthritis. Ann Intern Med. 2000, 133: 321-328.) Radiographs of the bilateral knees taken when [the] Veteran was 50 years old do not support any posttraumatic arthritis or degenerative changes. Therefore, it is less likely that the jumps he made as a young man induced sufficient microtrauma as to produce a chronic knee condition, or he would be more likely to exhibit osteoarthritis/degenerative joint disease of his knees during his fifth decade. There is otherwise no medical opinion linking a knee disability to service, and the undersigned finds the April 2016 opinion to be definitive as to this matter as it is documented to have been based on a consideration of the pertinent clinical history and lay history provided by the Veteran and is supported by a thorough rationale. To the extent the assertions of the Veteran or his attorney are advanced in an attempt to establish that the Veteran has a knee disability that is related to service, such complex medical matters are within the province of trained medical professionals. See Jones, supra. Again, as neither the Veteran nor his attorney are shown to have appropriate training and expertise, neither are competent to render a persuasive opinion as to this matter. While the Veteran is competent to describe lay observable symptoms associated with a left and right knee disability since service, the undersigned finds the negative April 2016 VA opinion and the lack of any objective post service evidence linking a current disability associated with a knee disability to service to be more probative than the lay assertions made in connection with the claims for service connection for left and right knee disabilities, and that these facts weigh against a finding of continuity of relevant symptoms associated with these conditions since service. In sum, the undersigned finds that the preponderance of the evidence is against the Veteran’s claims for service connection for a left or right knee disability. As such, these claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra.   3. Difficulty with Breathing/Left and Right Hand Numbness The STRs are silent for problems with breathing or left or right-hand numbness. VA medical opinions addressing the claims for these conditions were completed in March 2016 pursuant to the instructions of the July 2015 Board remand. These opinions are documented to have been based on a review of the clinical history contained in the claims file and to reflect consideration of the Veteran’s report of continuity of problems with breathing and bilateral hand numbness from service to the present time. The opinion with respect to difficulty with breathing was set forth as follows: [The Veteran] [s]tates he has anxiety and when he gets anxious he gets SOB [shortness of breath]. Also, if he is out walking, he will get SOB if he walks at a fast pace. Symptoms are primarily related to his diagnosis of anxiety, with most likely a strong component of deconditioning. [The] Veteran does not have any “objective indications of a chronic disability resulting from an undiagnosed illness.” The [V]eteran’s claimed breathing problems less likely as not represent a “medically unexplained chronic multisymptom illness.” As noted, his symptoms are at least as likely as not related to his anxiety and to deconditioning. Given the direct linkage of the Veteran’s difficulty with breathing to psychiatric problems in the opinion above, there is sufficient evidence of record to warrant a grant of service connection for the Veteran’s difficulty with breathing as secondary to service-connected psychiatric disability. Turning to bilateral hand numbness, the March 2016 opinion with respect to whether such was attributable to a “known clinical diagnosis” was as follows: The [hand numbness] complaints appear to be more consistent with positional pressure on a peripheral nerve rather than a pathological problem. This is support[ed] by the fact that his symptoms would resolve with simply changing position, and a benign nerve conduction test. The opinion with respect to whether the Veteran’s bilateral hand numbness included objective indications of a “chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period” was follows: Review of all VHA records, and any other medical records in the c-file are silent for any complaints or concerns about hand paresthesias since the exam of 7/26/11. Therefore[,] it does not appear to have persisted or have been of any concern to the [V]eteran. As to whether the Veteran’s bilateral hand numbness represents a “medically unexplained chronic multi symptom illness,” the opinion was as follows: The [V]eteran’s bilateral hand numbness less likely as not represents a “medically unexplained chronic multi symptom illness.” His complaints appear to be more positional in nature as noted above, and do not seem to have persisted or at least been of concern to this [V]eteran. With respect to whether the bilateral hand numbness was related to the Veteran's military service, to include his service in Southwest Asia, the response was as follows. No diagnosis or pathological condition was identified. There is otherwise no opinion indicating that the Veteran has a current disability associated with numbness in the left or right hand that is the result of service, to include based on the presumptions for Veterans who served in the Southwest Asia Theater of Operations. To the extent the assertions of the Veteran or his attorney are advanced in an attempt to establish that he has a current disability associated with numbness in the left or right hand that is due to service, such complex medical matters are within the province of trained medical professionals. As neither the Veteran nor his attorney are shown to have appropriate training and expertise, neither are competent to render a persuasive opinion as to this matter. See Jones, supra. While the Veteran is competent to describe having had bilateral hand numbness since service, the undersigned finds the silent STRs for such manifestations and the lack of any competent evidence linking bilateral hand numbness to service, to include on the basis of the presumption for Veterans who served in the Southwest Asia Theater of Operations, to be more probative than the lay assertions made in connection with the claims for service connection for left and right hand numbness, and that these facts weigh against a finding of continuity of bilateral hand numbness since service. In sum, the undersigned finds that the preponderance of the evidence is against the Veteran’s claims for service connection for left- and right-hand numbness, to include as a result of undiagnosed illness or other qualifying, chronic disability pursuant to 38 U.S.C. § 1117. As such, these claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. II. Increased Rating Claims A. General Legal Criteria Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. II. Increased While the Veteran’s entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Court has since held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. The effective date of an increased rating will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. B. Heartburn 1. Rating Criteria The Veteran’s heartburn is rated on the basis of a hiatal hernia under 38 C.F.R. § 4.114, DC 7346. The use of DC 7346 reflects that there is no diagnostic code specifically applicable to the Veteran’s service-connected heartburn and that this disability has been rated by analogy to hiatal hernia under DC 7346. See 38 C.F.R. § 4.20 (allowing for rating of unlisted condition by analogy to closely related disease or injury). Under DC 7346, a 10 percent rating is warranted for hiatal hernia with two or more of the symptoms for the 30 percent rating of less severity; a 30 percent rating is warranted for hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of a considerable impairment of health; and a 60 percent rating is warranted for hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, DC 7346. 2. Analysis Service connection for heartburn as secondary to service connected psychiatric disability was granted by a January 2011 rating decision at a disability rating of 30 percent under DC 7346 after a September 2010 VA examination found that it was at least as likely as not that the Veteran’s heartburn was caused by his service connected psychiatric disability. The 30 percent rating has been continued until the present time. At the September 2010 VA examination, the Veteran described typical reflux symptoms, particularly when recumbent at night, with brackish regurgitation of stomach fluid that tastes sour, sometimes accompanied by nausea or vomiting. He denied having hematemesis or melena. He reported episodes of food sticking occurring at up to one to two times a week, after which he would slow down his eating or take sips of water to recover from. The most recent VA examination to address the severity of the Veteran’s heartburn conducted in April 2016 pursuant to the directives of the July 2015 remand showed the Veteran reporting that he occasionally took Rolaids for relief of symptoms. He stated that his stomach prefers food that has minimal spice. The Veteran reported that he has not lost weight or suffered nutritional deficiency due to his heartburn or lost any time from work due to such. He denied dysphagia, arm or shoulder pain, symptoms that produce considerable impairment of health, material weight loss/malnourishment, anemia, or any symptom combinations productive of severe impairment of health. In the past year, the Veteran reported about a half dozen episodes of vomiting if he ate too much spicy food but indicted such episodes were not associated with hematemesis and did not require visits to the hospital. He also reported that has had no melena. To warrant a rating in excess of 30 percent for the Veteran’s heartburn under DC 7346, there must be symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. Aside from vomiting, such manifestations were specifically denied at the April 2016 VA examination, and review of the record does not otherwise reveal the manifestations required for a rating in excess of DC 7346. As such, and as a rating in excess of 30 percent would not be warranted under any other potentially applicable diagnostic code, a rating in excess of 30 percent for the Veteran’s heartburn is not warranted. C. Psychiatric Disability 1. Rating Criteria The General Rating Formula for Mental Disorders provide for a noncompensable rating for a formally diagnosed mental condition manifested by symptoms that are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent for psychiatric disorders is warranted if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A rating of 30 percent is warranted if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent disability rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the Veteran’s own occupation or name. 38 C.F.R. § 4.130. The symptoms recited in the rating schedule for evaluating mental disorders are “not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant’s service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. 2. Analysis After a July 2010 VA examination diagnosed the Veteran with PTSD with associated depression, an August 2010 rating decision granted service connection for PTSD with associated depression at a disability rating of 30 percent under DCs 9434 [major depressive disorder]-9411 [PTSD] effective from August 13, 2009. Such disability is rated under the General Rating Formula for Mental Disorders as set forth above. Service connection for panic disorder without agoraphobia and alcohol abuse was granted by a November 2011 rating decision, and such disability was rated in conjunction with the 30 percent rating assigned for PTSD with associated depression. The 30 percent rating for the service-connected psychiatric disorder was increased to 50 percent effective from October 23, 2012 by a December 2012 rating decision. A March 2013 rating decision assigned a 70 percent rating for this disability effective from April 22, 2011, the date of a visit to a VA mental hygiene clinic. As such, the matters for consideration are whether a rating in excess of 30 percent may be assigned for the service-connected psychiatric disability prior to April 22, 2011 and whether a rating in excess of 70 percent for this disability may be assigned for the period beginning April 22, 2011. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The evidence of record prior to April 22, 2011 includes the reports from the aforementioned July 2010 VA examination which noted that the Veteran’s psychiatric symptoms interfered with his ability to re-establish his marriage with his wife. The Veteran indicated that he had withdrawn from other people; that he did not have a social life with others; and that he did not participate in activities with others. Psychiatric symptoms were said to include anxiety, depression, flashbacks, difficulties sleeping, anxiety, and spontaneous panic episodes. An October 2010 VA psychiatric examination noted that the Veteran had ongoing problems with intrusive memories of combat situations in Iraq, to include being fearful of SCUD missile attacks. The Veteran reported that his anxiety level was high during the day and was getting worse. He also reported that he had difficulty sitting still and that he paced frequently at work. Panic symptoms were said to occur often, at least one or two times per day, often five days per week. The Veteran reported worsening depression over the prior 6 months and reported that he tends to isolate himself. He said his interest and motivation levels were generally low and that he found it difficult to motivate himself or muster enthusiasm for much. Upon mental status examination, the Veteran’s mood was quite anxious, and his affect was restricted and reserved. The Veteran’s social functioning was said to be somewhat impaired by his isolation due to his PTSD. Review of the clinical evidence above makes it clear that the psychiatric impairment, particularly due to his social isolation, was significant prior to April 22, 2011. Given this history, the undersigned find that it is at least as likely as not that the manifestations which were found to warrant a 70 percent rating for the Veteran’s PTSD were present prior to April 22, 2011, and cannot reasonably said to have only become first manifested at the time of the April 22, 2011 visit to a VA mental hygiene clinic. In short therefore, and bearing in mind the fact the applicable rating criteria are to be considered not as an exhaustive list of symptoms, but rather as examples of the type and degree of the symptoms or effects that would justify a particular rating, all reasonable doubt has been resolved in the Veteran’s favor such that the undersigned finds that the criteria for a 70 percent rating for the Veteran’s PTSD are met from the date of the grant of service connection for this disability, or August 13, 2009. 38 U.S.C. §§ 5107(b), 5110(a); 38 C.F.R. §§ 3.102, 3.400, 4.7, 4.130, DC 9411, 9434. As for a rating in excess of 70 percent for the Veteran’s PTSD, such would require total social and occupational impairment, with such severe symptoms that there be the equivalent of gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; or such severe memory loss that the Veteran could not remember his own name or close relatives or his own occupation or name. Weighing against the assigment of a 100 percent rating is the fact that in choosing the degree of the Veteran’s psychiatric impairment, the March 2016 VA examiner selected “occupational and social impairment with reduced reliability and productivity,” which matches the criteria for only a 50 percent rating under the General Rating Formula for Mental Disorders. Also weighing against a finding of total social and occupational impairment is the fact that the mental status examination conducted in March 2016 showed the Veteran to be alert and fully oriented with a clear sensorium and his attention and concentration were good. Moreover, the Veteran’s affect was consistent with his mood and his thoughts were logical, organized, and goal directed. Finally, the March 2016 VA examination noted that the Veteran’s marriage had been stable since 2015 and that he and his wife had been getting along better since his most recent move. Given the above and in short, the undersigned finds that a rating in excess of 70 percent for the Veteran’s PTSD for the period beginning August 13, 2009 cannot be assigned. Again, in making this determination, the applicable rating criteria have not been considered as an exhaustive list of symptoms, but rather as examples of the type and degree of the symptoms or effects that would justify a particular rating, and the undersigned has not required the presence of a specified quantity of symptoms in the rating schedule in order to warrant a rating in excess of 70 percent for the service connected PTSD for the period beginning August 13, 2009. D. Final Considerations In making the negative determinations above, the undersigned has considered carefully the Veteran’s contentions with respect to the nature of the service-connected disabilities at issue and notes that his lay testimony is competent to describe certain symptoms associated with these manifestations. However, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected manifestations at issue. As such, while the undersigned accepts the Veteran’s testimony with regard to the matters he is competent to address, more probative weight is place on the competent medical evidence with regard to the specialized evaluation of functional impairment; namely, the assessments of the severity of disability due to the service-connected disabilities in the clinical evidence discussed above. Finally, in making the negative rating determinations above, the undersigned has considered the doctrine of reasonable doubt but finds that the preponderance of the evidence is against the assignment of ratings in excess of 30 percent for a disability manifested by heartburn as secondary to service connected psychiatric disability and in excess of 70 percent rating for PTSD with depression, panic disorder without agoraphobia, and alcohol abuse for the period beginning August 13, 2009. As such, entitlement to increased compensation for a disability manifested by heartburn as secondary to service connected psychiatric disability in excess of 30 percent or a rating in excess of 70 percent rating for PTSD with depression, panic disorder without agoraphobia, and alcohol abuse for the period beginning August 13, 2009 may not be granted. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7; Gilbert, supra. III. Extension of a Convalescent rating under 38 C.F.R. § 4.30 after July 31, 2013 for Right Shoulder Impingement Status Post Arthroscopic Subacromial Decompression A. Legal Criteria A total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted, effective from the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release. 38 C.F.R. § 4.30. In order to attain the temporary total disability rating, the Veteran must demonstrate that his service connected disability resulted in: (1) surgery necessitating at least one month of convalescence; (2) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30(a). An extension of 1, 2, or 3 months beyond the initial 3 months of temporary total rating for convalescence may be granted and extensions of 1 or more months up to 6 months beyond the initial 6 months period may be made, upon request. 38 C.F.R. § 4.30(b). B. Analysis The November 2018 rating decision that granted service connection for right shoulder impingement status post arthroscopic subacromial decompression assigned a 100 percent rating for such disability effective from June 17, 2013 under 38 C.F.R. § 4.30 for convalescence. A 20 percent rating was assigned following the expiration of this rating effective from August 1, 2013. The Veteran requests an extension of his 100 percent rating assigned under 38 C.F.R. § 4.30 after July 31, 2013. Review of the record reflects reports from an arthroscope with subacromial decompression of the right shoulder on June 17, 2013, which was the basis for the temporary 100 percent rating under 38 C.F.R. § 4.30 discussed above. These reports indicate the surgery did not involve any complications and that it was well tolerated by the Veteran. He was discharged on the same day of the procedure with his right arm immobilized. A follow up visit on July 17, 2013 noted that Veteran was “doing well” with his range of motion in his right shoulder and that no post-operative physical therapy was required. Thereafter, a September 6, 2013, orthopedic surgery note showed the Veteran reporting that his right shoulder was “much improved.” The examination of the right shoulder conducted at that time showed well healed surgical portals with no erythema, swelling, or effusion. He had abduction and forward flexion of the right shoulder to about 170 degrees without pain. Strength was 5/5 with resistance to abduction and internal and external rotation. Physical therapy was ordered at that time, and a September 20, 2013, physical therapy note indicated the Veteran’s report that he seemed to be doing well with all range of motion and strength in the right shoulder. An October 24, 2013, VA orthopedic surgery note reflected the Veteran reporting improvement in his right shoulder. The physical examination of the right shoulder at that time again revealed well healed surgical portals and no erythema, swelling or effusion. He again demonstrated abduction and forward flexion to about 170 degrees without pain, and strength was to 5/5 with resistance to abduction and internal and external rotation. The Veteran did undergo a subacromial injection due to impingement signs demonstrated at that time. Thereafter, a February 19, 2014, VA orthopedic surgery note indicated that the Veteran had recovered “fairly well” from his right shoulder surgery, and that the symptoms had improved for two to three months after the surgery. However, he did describe some lingering pain, particularly at night, that was helped with rest and relaxation. The October 2013 injection was said to have helped for 30 days. An MRI was ordered due to the fact that the Veteran had some ongoing symptoms, and the results from such were as follows: No tears of the rotator cuff muscles or tendons are identified. Mild tendinopathy in the supraspinatus. No glenohumeral joint effusion. No substantial arthropathy at the acromioclavicular joint. No tear of the glenoid labrum and no bony injury to the glenoid rim. In short, while review of the evidence above reflect some lingering right shoulder symptoms after the right shoulder surgery in question, it does not indicate that for the period of time after July 31, 2013, that residuals of this surgery necessitated at least one month of convalescence; surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches; or immobilization by cast, without surgery, of one major joint or more so as to warrant the extension of benefits under 38 C.F.R. § 4.30 beyond July 31, 2013. There is otherwise no clinical evidence of record indicating that an extension of benefits under 38 C.F.R. § 4.30 for the right shoulder surgery in question beyond July 31, 2013 would be warranted. In short, while the lay assertions of the Veteran and his attorney as to their belief that an extension of the benefits provided by 38 C.F.R. § 4.30 in question is warranted, the Board finds the probative weight of these contentions to be overcome by the objective clinical evidence of record, to include that set forth above. As such, the claim for an extension of a convalescent rating under 38 C.F.R. § 4.30 after July 31, 2013 for right shoulder impingement status post arthroscopic subacromial decompression must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra.   IV. Earlier Effective dates for Service Connection for Right Shoulder and Right Elbow Disabilities A. Legal Criteria The assignment of effective dates of VA awards is generally governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on a claim for compensation (i.e., service connection) “shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor.” 38 U.S.C. § 5110(a), 38 C.F.R. § 3.400(b)(2). The implementing regulation clarifies this to mean that the effective date of service connection/compensation will be, “[d]ate of receipt of claim or date entitlement arose, whichever is later.” 38 C.F.R. § 3.400. If a claim for service connection for a disability is filed within one year of separation from active service, the effective date of an award of compensation for such disability shall be the day following separation from active service. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). Effective March 24, 2015, VA amended its adjudication regulations to require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary. See 79 Fed. Reg. 57,660 (Sept. 25, 2014). This rulemaking also eliminated the constructive receipt of VA reports of hospitalization or examination and other medical records as informal claims for increase, and revised 38 C.F.R. § 3.400(o)(2). These amendments are applicable with respect to claims and appeals filed on or after March 24, 2015, Id. at 57,686. As the appeal and claims at issue pre-date March 24, 2015, these amendments are not for application. Prior to the amendments discussed above, any communication indicating intent to apply for a benefit under the laws administered by the VA may be considered an informal claim provided it identifies, but not necessarily with specificity, the benefit sought. 38 C.F.R. § 3.155(a) (2014). To determine when a claim was received, all communications in the claims file that may be construed as an application or claim were for consideration. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). The benefit sought must be identified (see Stewart v. Brown, 10 Vet. App. 15, 18 (1997)), but need not be specific (see Servello v. Derwinski, 3 Vet. App. 196, 199 (1992)). 38 C.F.R. § 3.155(a) also provided that upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within 1 year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. B. Analysis Service connection for right shoulder impingement status post arthroscopic subacromial decompression, limitation of extension due to lateral epicondylitis of the right elbow is denied, and impairment of supination and pronation due to lateral epicondylitis of the right elbow was granted effective from August 13, 2009—the date of receipt of the claims for service connection for these disabilities by way of a VA Form 21-526, Veteran's Application for Compensation and/or Pension received on that date. As clearly indicated above, even under the prior regulations, for service connection for a disability to be granted, there must be some type of communication that may be construed as a claim for service connection for such disability. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.155(a). In this case, there is no other communication of record dated or received prior to the August 13, 2009, application that represents a claim for service connection for a right shoulder or right elbow disability. See Servello, supra [the Board must look at any communication that can be interpreted as a claim, formal or informal, for VA benefits]. Also considering the prior regulations, there was no informal claim for service connection for a right shoulder or right elbow disability filed prior to August 13, 2009 because no communication was ever filed prior to that time indicating the Veteran’s intent to apply for service connection for these disabilities. An informal claim must identify the benefit sought. See Brannon v. West, 12 Vet. App. 32, 34-35 (1998) (noting that VA “is not required to anticipate a claim for a particular benefit where no intention to raise it was expressed,” and citing Talbert v. Brown, 7 Vet. App. 352, 356-57 (1995), for the proposition that VA is not required to do a “prognostication” or “conjure up” issues that were not raised by the appellant, but to review issues reasonably raised by the substantive appeal). These cases make it evident that medical records generally cannot be construed as constituting an informal claim for service connection. Such records may be construed as an informal claim for an increased disability rating or to reopen a compensation claim originally denied by reason of not being compensable in degree, but that is not the situation in the instant case. See 38 C.F.R. § 3.157 (2014). Given the above and in short, the earliest effective date that can be granted for service connection for right shoulder impingement status post arthroscopic subacromial decompression, limitation of extension due to lateral epicondylitis of the right elbow, and impairment of supination and pronation due to lateral epicondylitis of the right elbow under the controlling legal criteria is the date of receipt of the claim for service connection for these disabilities on August 13, 2009. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400(b)(2)(2019). The Board reiterates that the legal authority governing effective dates is clear and specific, and the Board is bound by such authority. As such, on these facts, there is no legal basis for an award of service connection for right shoulder impingement status post arthroscopic subacromial decompression, limitation of extension due to lateral epicondylitis of the right elbow or impairment of supination and pronation due to lateral epicondylitis of the right elbow prior to the date of receipt of the claim for that benefit. As such, the claims for an earlier effective date for service connection for these disabilities prior to the August 13, 2009, date of receipt of the claims for service connection for these disabilities must be denied as without legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). V. Effective Date Pior to June 17, 2013 for SMC Based on Being Housebound and Entitlement to this Benefit After August 1, 2013 A. Legal Criteria The SMC “housebound” benefit provided by 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i) is payable where the Veteran has a single service-connected disability rated as 100 percent and either has additional service-connected disability or disabilities independently rated as 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems or is permanently housebound by reason of service-connected disability or disabilities. The “housebound” requirement is also met when the Veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. B. Analysis The aforementioned November 2018 rating decision granted SMC under the provisions of 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i) for the period from June 17, 2013 to August 1, 2013. The Veteran asserts that he is entitled to the benefit both before June 17, 2013, and after August 1, 2013. As set forth in the November 2018 rating decision November 2018 rating decision, this benefit was assigned not on the basis of the Veteran being found to be “substantially confined as a direct result of service-connected disabilities to his her dwelling and the immediate premises” as set forth under the regulation above, but on the basis of the assignment of the temporary 100 percent rating for the service connected right shoulder disability under 38 C.F.R. § 4.30 effective from June 17, 2013 in conjunction with additional service connected conditions being independently rated as 60 percent disabling. Given the expiration of the 100 percent rating for the service connected right shoulder disability under 38 C.F.R. § 4.30 effective from July 31, 2013, the criteria for benefits provided by 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i) expired on July 31, 2013 as the Veteran did not have a single service-connected disability rated as 100 percent after July 31, 2013. As indicated in the Board’s adjudication decision above, entitlement to a temporary 100 percent rating for the service-connected right shoulder disability under 38 C.F.R. § 4.30 was granted effective from the date that the Veteran underwent arthroscopic subacromial decompression surgery at a VA medical facility, June 17, 2013. It is not shown that any surgery warranting entitlement to a temporary 100 percent rating was conducted prior to June 17, 2013, or that a single 100 percent rating was warranted for any service-connected disability prior to that date. Thus, as it also shown or contended that the Veteran was substantially confined as a direct result of service-connected disabilities to his dwelling and the immediate premises prior to that date, entitlement to SMC under the criteria set forth at § 1114(s); 38 C.F.R. § 3.350(i) prior to June 17, 2013 cannot be granted. Sabonis, supra. With respect to whether benefits provided by § 1114(s); 38 C.F.R. § 3.350(i) may be assigned after July 31, 2013, the Board’s adjudication in this decision above determined that entitlement to a temporary 100 percent rating for the service connected right shoulder disability under 38 C.F.R. § 4.30 after July 31, 2013 was not warranted, and, again, it also not shown or contended that the Veteran was substantially confined as a direct result of service-connected disabilities to his her dwelling and the immediate premises after that date. In short therefore, entitlement to SMC under the criteria set forth at § 1114(s); 38 C.F.R. § 3.350(i) after July 31, 2013 also cannot be granted. Id. REMANDED The March 2016 VA psychiatric examination indicated the Veteran was no longer working, and the Veteran’s attorney appeared to raise the matter of entitlement to TDIU in a November 2018 statement. As such, a claim for entitlement to TDIU has been raised by the record, and this matter will be referred to the Agency of Original Jurisdiction (AOJ) for initial adjudication. Rice v. Shinseki, 22 Vet. App. 447 (2009). With respect to the claims for increased ratings for the service connected residuals of a right ankle fracture with degenerative joint disease; right shoulder impingement status post arthroscopic subacromial decompression; limitation of extension due to lateral epicondylitis of the right elbow; and impairment of supination and pronation due to lateral epicondylitis of the right elbow, the Veteran has not been afforded VA examinations addressing these claims that contain the findings required by Correia v. McDonald, 28 Vet. App. 158 (2016). As such, the AOJ will be requested to afford the Veteran VA examinations addressing these claims that contain the findings required by Correia. The remand of the increased rating claims will also afford the AOJ the opportunity to ensure that the findings with respect to flare-ups required by Sharp v. Shulkin, 29 Vet. App. 26 (2017) are obtained. Finally, with respect to the claim for service connection for sleep apnea to include as secondary to service-connected psychiatric disability, the January 2018 VA opinion that addressed this claim did not address the matter of whether the Veteran’s service-connected psychiatric disability aggravated his sleep apnea. As such, an addendum opinion from the clinician who completed the January 2018 that addressed this matter is necessary to fulfill the duty to assist. For the reasons stated above, this case is REMANDED to the AOJ for the following action: 1. Update VA and private records. 2. Schedule the Veteran for examinations by an appropriate clinician(s) to determine the current severity of his service-connected right ankle, right shoulder impingement status post arthroscopic subacromial decompression; and limitation of extension due to lateral epicondylitis of the right elbow; and impairment of supination and pronation due to lateral epicondylitis of the right elbow. The examiners should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disabilities under the rating criteria. In so doing, each examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, each examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Also in doing so, each examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups and with repeated use over time. If it is not possible to provide a specific measurement based on direct observation, each examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups and with repeated use over time based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Obtain an addendum opinion from the January 2008 examiner, or suitable substitute if this examiner is not available, as to whether it as at least as likely as not that the Veteran’s service-connected psychiatric disability has aggravated his sleep apnea. 4. Adjudicate the claim for TDIU. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Andrew Ahlberg, 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.