Citation Nr: 21062824 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 13-24 904A DATE: October 12, 2021 ISSUES 1. Entitlement to service connection for left foot bone spurs. 2. Entitlement to service connection for right foot bone spurs. 3. Entitlement to service connection for left foot corns. 4. Entitlement to service connection for right foot corns. 5. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected sinusitis. 6. Entitlement to service connection for hypertension, to include as secondary to service-connected sinusitis. 7. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and claimed as a major depressive disorder (MDD), with anxiety, bad dreams, and night sweats. 8. Entitlement to service connection for tension headaches, to include as secondary to an acquired psychiatric disorder. 9. Entitlement to assignment of a 10 percent evaluation under 38 C.F.R. § 3.324, based on multiple, noncompensable, service-connected disabilities, prior to August 5, 2013. 10. Entitlement to a total disability rating based on individual unemployability (TDIU). ORDER Entitlement to service connection for left foot bone spurs is denied. Entitlement to service connection for right foot bone spurs is denied. Entitlement to service connection for left foot corns is denied. Entitlement to service connection for right foot corns is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected sinusitis, is denied. Entitlement to service connection for hypertension, to include as secondary to service-connected sinusitis, is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and claimed as a major depressive disorder (MDD), with anxiety, bad dreams, and night sweats is remanded. Entitlement to service connection for tension headaches, to include as secondary to an acquired psychiatric disorder, is remanded. Entitlement to assignment of a 10 percent evaluation under 38 C.F.R. § 3.324, based on multiple, noncompensable, service-connected disabilities, prior to August 5, 2013 is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran does not have a left foot bone spurs disability. 2. The Veteran does not have a right foot bone spurs disability. 3. The Veteran does not have a left foot corns disability. 4. The Veteran does not have a right foot corns disability. 5. The claimed foot impairment is attributable to already service-connected pes planus, hammer toes, degenerative arthritis, hallux valgus, and tineas pedis of the bilateral feet. 6. Gastroesophageal reflux disease (GERD) was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 7. Hypertension was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. CONCLUSIONS OF LAW 1. A left foot bone spurs disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. A right foot bone spurs disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. A left foot corns disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. A right foot corns disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 5. Gastroesophageal reflux disease (GERD) was not incurred in or aggravated by service, ulcers may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 6. Hypertension was not incurred in or aggravated by service, cardiovascular-renal disease may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1979 to October 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision by the Montgomery, Alabama, Regional Office (RO) of the United States Department of Veterans Affairs (VA). The Veteran testified at an October 2015 hearing held before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. The Board observes that a February 2016 Board Decision and Remand reopened the previously denied claims of service connection for blurred vision, an upper respiratory condition, claimed as allergic rhinitis and sinusitis, and an acquired psychiatric disorder, claimed as a major depressive disorder, anxiety, and night sweats. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Court held that the scope of a mental health disability claim includes any mental health disability that could reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Based on the exchange with the Veteran at the hearing, the claims with regard to the lungs and acquired psychiatric disorders were combined and recharacterized. The claim with regard to 38 C.F.R. § 3.324 was recharacterized to reflect that as of August 5, 2013, the Veteran was in receipt of compensation benefits based on a compensable rating for a service-connected disability. Next, an October 2016 rating decision granted service connection for pes planus, hammer toes, degenerative arthritis and hallux valgus of the bilateral feet, chronic sinusitis, left knee strain, right knee strain, and tinea pedis of the bilateral feet. Previously, the Veteran and his representative submitted a February 2019 Informal Hearing Presentation (IHP). The list of issues includes entitlement to service connection for erectile dysfunction. However, the IHP was not clear as to whether the Veteran is attempting to raise a new claim. The RO has not adjudicated this issue. To the extent that the Veteran desires to file a claim for service connection for an erectile disability, he is advised that a complete claim on an application form prescribed by VA regulations is required. 38 C.F.R. § 3.155. Therefore, the Board determined in January 2021 that it did not have jurisdiction over it, and it was referred to the RO for appropriate action. 38 C.F.R. § 19.9 (b). Overall, the issues currently on appeal have been remanded by the Board in April 2019 and again in January 2021 for additional development. These issues are now back before the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97 (2008). As a separate matter, at the RO level, several rating decisions have been issued during the pendency of his appeals. A March 2020 Rating decision confirmed and continued the previous denial of service connection for diabetes mellitus. Months later, an August 2020 rating decision granted some claims, confirmed and continued others, and denied several claims unrelated to the current appeals stream. Also in August 2020, the Veteran filed a VA 21-526EZ Application for Disability Compensation and Related Compensation Benefits. During the course of development, additional claims have been received, and additional rating decisions have been issued by the RO. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). By way of background, the Veteran was mailed a May 12, 2016 VA Form 21-4142, Authorization to Disclose Information, and VA Form 21-4142a, General Release for Medical Provider Information, so that VA could obtain treatment information relevant to his claim. VA subsequently made attempts to obtain the requested records from the identified providers. VA informed the Veteran that it is ultimately his responsibility to submit relevant evidence in private treatment records to support his claim. The Board observes that VA has made several attempts to obtain VA treatment records, including from the East and West campuses of the Central Alabama Veterans Health Care System from October 1986 to the present. An October 2018 letter from the Central Alabama Veterans Health Care System shows that a thorough search was conducted, but no records are available prior to 2003 in the system or records. An October 22, 2018 Report of General Information confirmed this finding. Nevertheless, VA treatment records from 2003 were still obtained and associated with the claims file. In addition, throughout 2020, ongoing VA treatment records were associated with the claims file. Significantly, the Veteran and his representative filed a December 2020 Informal Hearing Presentation (IHP). In the IHP, they raise several contentions regarding each issue. Ultimately, as discussed in greater specificity below, a remand was requested for each issue. In January 2021, the Board remanded the issues to ensure that the Veteran was afforded due process. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Pursuant to the January 2021 Board Remand, the Veteran was invited to supplement the record with any private medical opinions. Next, the Veteran and his representative were sent February 9, 2021, March 12, 2021, and April 21, 2021 VA Subsequent Development Letters. They included a request for details of the claimed personal trauma incidents related to the PTSD claim, with an attached VA 21-0781. In the most recent letter, VA noted that two previous copies of this had been sent. To date, no direct response has been received. We discuss this in the Remand section below. Recently, through his representative submitted an August 2021 IHP. In the IHP, they note the VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability is from 2009. They request that an updated form be sent by the AOJ to the Veteran, and that records from the Social Security Administration (SSA) be obtained. For this issue and the 38 C.F.R. § 3.324, issue, they conclude, "A further remand is indicated." Nevertheless, the Board has sufficient evidence and there is no objection to deciding several other issues on appeal at this time. The Veteran in this case has not referred to any other deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). SERVICE CONNECTION To establish service connection a Veteran must generally show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). We note that hypertension as cardiovascular-renal disease is a chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Under 38 C.F.R. § 3.303 (b), service connection may be established by demonstrating continuity of symptomatology. Continuity may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. The provisions of 38 C.F.R. § 3.303 (b) only apply to diseases recognized by VA as "chronic." See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303 (b), 3.309(a). Chronic diseases that become manifest to a degree of 10 percent or more within one year of termination of active duty may be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 1. Entitlement to service connection for left foot bone spurs 2. Entitlement to service connection for right foot bone spurs 3. Entitlement to service connection for left foot corns 4. Entitlement to service connection for right foot corns The Board incorporates its discussion from the sections above by reference. The Board observes that the Veteran is already service-connected for pes planus, hammer toes, degenerative arthritis, and hallux valgus of the bilateral feet, in addition to tinea pedis of the bilateral feet. The instant claims remain as distinct issues encompassing the claimed impairment, exclusive of that which is already service-connected. 38 C.F.R. § 4.14. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). By way of evidentiary history, the Service Treatment Records (STRs) include a Report of Medical Examination from separation. It disclosed a clinically normal evaluation of the feet, lower extremities, and skin, lymphatics. In the contemporaneous Report of Medical History, the Veteran described his health as "Good." He denied tumor, growth, cyst, or cancer, lameness, bone, joint, or other deformity, and foot trouble. Later, the issues of service connection for bone spurs and corns of the bilateral feet were remanded by the Board in February 2016 as part of a broader remand for a VA foot examination. The remand directives included, "Review the claims file to ensure that all of the foregoing requested development is completed, and arrange for any additional development indicated. Then readjudicate the claims on appeal. If any of the benefits sought remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order." (emphasis added). Next, the June 2016 VA foot conditions examination contains a medical history documenting in part, "The Veteran has a diagnosis of spurs or corns of the feet." The Board notes this was uploaded in August 2016. Next, an October 2016 rating decision granted service connection for pes planus, hammer toes, degenerative arthritis and hallux valgus of the bilateral feet with an evaluation of 30 percent effective April 9, 2009. The October 2018 Supplemental Statement of the Case (SSOC) does not reflect consideration of these issues, which were not addressed in the October 2016 rating decision. The February 2019 IHP reflects the issues of service connection for left foot corns, and right foot corns, while omitting bilateral bone spurs. Next, in April 2019, the Board previously determined that a remand was necessary for additional development in compliance with the Board's February 2016 remand directives and the governing law. See Stegall, D'Aries, both supra; 38 C.F.R. §§ 19.31, 19.37. The Veteran was subsequently issued the June 2020 SSOC informing him of the evidentiary requirements necessary to substantiate his claims. In response, by way of the December 2020 IHP, the Veteran through his representative presented new evidentiary and duty to assist arguments. First, the Veteran challenged the adequacy of the August 2016 VA foot conditions examination. The Veteran asserted, "This C&P also stated that this veteran also had bone spurs and corns on his feet, however, did not give a diagnosis date for either. These conditions were also not included in the medical opinion or VA Decision of October 2016 only the first three conditions which were combined into one service connected disability. It is unclear why these conditions were not previously included in the granting of service connection for this veteran's bilateral feet." In the January 2021 Remand, the Board found these arguments persuasive to the extent there is additional evidence to be considered by the VA examiner in rendering a complete medical opinion. 38 U.S.C. § 5103A (d); 20 Vet McLendon v. Nicholson. App. 79 (2006). Accordingly, the Veteran was afforded a May 2021 VA foot conditions examination complete with Disability Benefits Questionnaire (DBQ) and medical opinions. The VA examiner elicited a lay history from the Veteran, reviewed the entire claims file, and performed a physical examination. The VA examiner identified bilateral flat feet, hammer toes, hallux valgus, and degenerative arthritis. The VA examiner provided a detailed medical history: Veteran is SC for pes planus, hammer toes, hallux valgus and degenerative arthritis bilateral feet. Veteran reports no noted hx of bone spurs to either foot. Reports using arch supports for pes planus with little relief. No hx of surgery to either foot. No hx of plantar fasciitis. Complains of bilateral foot pain with weight bearing several hundred feet. Complains of sharp pain to plantar aspect bilateral feet. The Veteran reports hx of painful corns to both feet in the area of his bunions bilaterally until about 18 months ago when corns spontaneously resolved, veteran is unsure when he developed corns but was seen or treated for corns during service. Denies any specific treatment for corns. Veteran reports no current corns, report resolved about 1.5 years ago. Veteran denies any corns during service. Review of available STRs are negative for foot complaints or treatment. Entrance exam does note second degree Pes Planus. The 12/2020 IHP and the Mayo clinic link cited are reviewed and appreciated. On current exam veteran denies being seen or treated for foot complaints during active service. Review of available STRs are negative for foot related complaints. Current radiographs are negative for bone spurs and current physical exam is negative for corns or calluses to either foot. Next, the VA examiner documented the impressions from contemporaneous imaging. They read: 5/10/2021 Right Foot Weight Bearing Impression: Moderate hallux valgus with mild midfoot and great toe DJD and pes planus. 5/10/2021 Left Foot Weight Bearing Impression: Pes planus and mild DJD. Next, the VA examiner rendered a comprehensive set of medical opinions at the end of the same document used for other conditions below. First, the VA examiner rendered a negative nexus opinion implicitly encompassing all theories of direct and presumptive service connection. The rationale is substantially the same as found in the medical history from the DBQ. It concludes, "Review of available STRs are negative for foot related complaints. Current radiographs are negative for bone spurs and current physical exam is negative for corns or calluses to either foot." Similarly, for any aggravation, the VA examiner rendered a negative nexus opinion. The VA examiner considered the contentions in the IHP and Mayo Clinic literature. The VA examiner highlighted that the contemporaneous imaging was negative for bone spurs and the current physical examination was negative for corns or calluses to either foot. Using his medical expertise, the VA examiner elaborated: Reasonably speaking, bone spurs of the feet do not resolve and should be evident on current radiographs. Reasonably speaking, the corns spontaneously resolved with no evidence of aggravation due to current SC foot conditions Current SC foot conditions are still present and as such no evidence of aggravation of bone spurs or corns since neither are currently present on exam or radiograph. The August 2021 Informal Hearing Presentation (IHP) does not contain specific argument or evidence challenging the findings of the May 2021 VA examiner. The Veteran contends that he is entitled to service connection for left and right foot bone spur and corn disabilities. The most probative evidence is the contemporaneous treatment records, including the STRs, and the findings of the May 2021 VA examiner. First, the Report of Medical Examination from separation disclosed a clinically normal evaluation of the feet, lower extremities, and skin, lymphatics. In the contemporaneous Report of Medical History, the Veteran described his health as "Good." He denied tumor, growth, cyst, or cancer, lameness, bone, joint, or other deformity, and foot trouble. There are no other signs, symptoms, or complaints of bone spurs or corns causing impairment of the bilateral feet. Here, the Board finds the lack of objective medical evidence as to the existence and diagnosis for a current chronic left or right foot bone spur and/ or corn disability to be the highly probative. This is demonstrated by the silence in the ongoing VA treatment records, and confirmed by the recent imaging at the May 2021 VA examination. The Board observes that neither the Veteran nor his representative have identified evidence to the contrary or specifically requested any additional development of these issues. Indeed, the May 2021 VA examiner cited imaging revealing: 5/10/2021 Right Foot Weight Bearing Impression: Moderate hallux valgus with mild midfoot and great toe DJD and pes planus. 5/10/2021 Left Foot Weight Bearing Impression: Pes planus and mild DJD. The VA examiner concluded, "Current radiographs are negative for bone spurs and current physical exam is negative for corns or calluses to either foot." He essentially explained that bone spurs do not spontaneously resolve and would be evident on imaging, if they ever existed. This finding was based upon his medical expertise. The Veteran's own lay history is consistent with the other reported clinical findings. On page 2 reads in part, "Veteran reports hx of painful corns to both feet in the area of his bunions bilaterally until about 18 months ago when corns spontaneously resolved, veteran is unsure when he developed corns but was seen or treated for corns during service." In reaching these conclusions regarding no current corn and bone spur disability, the May 2021 VA examiner reviewed the entire claims file and considered such lay statements. He added negative nexus opinions for all possible theories of entitlement. They are supported by the objective evidence in the claims file, as cited to by the VA examiner. Therefore, we assign the most probative weight to the negative nexus opinions of the May 2021 VA examiner. To the extent there is a reference to bone spurs in the June 2016 VA foot conditions examination, it was not confirmed by the contemporaneous imagining. There are only two references to bone spurs or corns of the feet in the Medical History section. In other words, the Veteran carried the possible diagnosis, but the disease entities were not identified that day. Bone spurs or corns were not listed in the findings later in the examination based upon imaging. Imaging on pages 7 and 8 of the examination showed hallux valgus, pes planus, mild osteoarthritis, and right-sided dorsal talar osteophyte formation. Even assuming bone spurs or additional, non-service connected foot disability was identified, although we do not concede this, there is still no nexus. The separation examination is negative for such foot pathology. There are now a set of negative nexus opinions. Moreover, as explained by the May 2021 VA examiner, it would be unlikely that bone spurs manifest and then resolved. In other words, with only brief references to bone spurs in June 2016, it is unlikely the Veteran ever had this diagnosed condition. Once again, the May 2021 VA examiner considered contemporaneous imaging of the feet and applied his medical expertise in reaching his conclusions. The May 2021 VA examiner's detailed findings outweigh brief historical references in the June 2016 VA examination. We have found the most probative evidence to be the May 2021 VA examination. In summary, the May 2021 VA examiner found no objective evidence of additional bilateral corn or bone spur disability, exclusive of that which is already service-connected. The VA examiner still considered the Veteran's lay evidence. In this regard, we have specifically considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). The Federal Circuit found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability." The Board observes that Saunders does not eliminate the need for underlying pathology, disease, or injury (also sometimes called a diagnosis). Specifically, we note that the recent May 2021 VA examination, there was no objective evidence of bone spurs or corns on imaging. There was a lay reported history of pain, however, the Veteran is already service-connected for several disabilities of the bilateral feet. In short, there was no additional functional impairment due to pain alone as is addressed by Saunders and not contemplated by the current ratings. Therefore, even after considering Saunders, service connection for a left and right foot bone spur and corn disabilities is not warranted. In sum, we find the lack of objective medical evidence as to the existence and diagnosis for any additional left and right foot bone spur and corn disabilities to be probative. Any lay reports of right and left foot corn and bone spur disabilities fail to be substantiated by contemporaneous imaging. We have assigned the most probative weight to the findings of the May 2021 VA examiner. The VA examiner provided complete reasons and bases in finding no bone spur or corn disabilities based upon imaging and his medical expertise. Any claimed "corns" or "bone spurs" disabilities were unrelated to service, and were acute, transitory, and resolved without residuals. There is no other objective evidence to the contrary. The August 2021 IHP does not raise any objections to the current examination results. In reaching this decision, we have considered that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. Saunders, supra. However, such is not the case, and any pain is attributable to the set of service-connected bilateral feet disabilities. Even assuming various corn or bone spur pathology were identified, though we do not concede this, there is still no link to service (nexus). There is no doubt to resolve. Therefore, service connection for left and right foot bone spur and corn disabilities is not warranted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 5. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected sinusitis The Board incorporates its discussion from the sections above by reference. By way of background, the Service Treatment Records (STRs) include a Report of Medical Examination from separation. It disclosed a clinically normal evaluation of the abdomen and viscera, mouth and throat, and lungs and chest. In the related Report of Medical History, the Veteran denied frequent indigestion and stomach, liver, or intestinal trouble. Years later, a January 30, 2018 VA Primary Care Note shows in part, "GERD on omeprazole that controls symptoms." Next, the October 2018 Supplemental Statement of the Case (SSOC) conceded the presence of disability in the VA treatment records. It noted the inability of VA to obtain treatment records prior to 2003, as discussed in the VCAA section above. There was still no nexus. The Veteran through his representative once again raised this issue in the February 2019 IHP. It shows, "Reflux is a common side effect of many pain medications. NSAIDs are notorious for this." The Board observed in April 2019 that this can be construed as a secondary service connection theory of entitlement. The Veteran was afforded a series of VA medical opinions in December 2019. For GERD, the VA examiner reviewed the entire claims file and performed a physical examination. The VA examiner rendered a negative nexus opinion for direct service connection. She cited the remote onset of GERD 18 years after separation. In a separate document, the VA examiner indicated that she could not determine a baseline of severity based upon the available medical evidence. Still, she ultimately opined that GERD is less likely as not aggravated beyond its natural progression due to or the result of service connected conditions. The VA examiner reasoned: While NSAID use can lead to symptoms of GERD, unable to determine chronic NSAID use within current available medical records. Documentation from 12/8/2016 notes "1 month ago came off binge drinking and smoking, reflux since." Heavy drinking is a risk factor for GERD and can cause damage to the esophageal mucosa. The conditions of groin rash, pes planus, hammer toes, degenerative arthritis and hallux valgus of bilateral feet, limitation of flexion of bilateral knees, tinea pedis, bilateral knee strain, nasal deviation, residuals of fracture nose, chronic sinusitis, hemorrhoids, and pseudofolliculitis barbae are not known causes or risk factors for the development or aggravation of GERD. Therefore the current condition of GERD is less likely as not aggravated beyond its natural progression due to or the result of SC conditions. Next, the Veteran and his representative challenged the conclusions of the VA examiner by way of the December 2020 IHP. They contend: Mr. [Veteran] is currently service connected for chronic sinusitis (0 percent). While there is not absolute proof that sinusitis causes GERD, it is highly likely that the symptoms between sinusitis and GERD are confused with one another as both can be associated with sore throats and chronic coughs. This veteran was treated several times during service for sore throats, sinus problems and an upset stomach. It is very likely that Mr. [Veteran] also suffered from GERD while in service, however, his sinus condition was more prevalent at the time and was likely overlooked. It is appears that Mr. [Veteran] did not know or understand what GERD was and since he had been treated for chronic sinusitis during service and post service, again, his GERD was overlooked. The Veteran's representative went on to highlight that medical treatment records show treatment for GERD over "many, many years." The VA examiner found that the Veteran's lay evidence establishes considerable NSAID use while in service and post service, which establishes their "chronic use." The Veteran through his representative concluded, "We believe the 2019 C&P to be inadequate as the examiner used the lack of documentation regarding the use of NSAID's against this veteran. We would recommend that an independent medical opinion be requested should this case be remanded." For this issue, the Board found in January 2021 that the VA examination does not fully address the Veteran's theory of entitlement as described in the December 2020 IHP. 38 U.S.C. § 5103A (d); McLendon v. Nicholson. In light of the representative's contentions, the Board found that a remand for a supplemental VA medical opinion was warranted. Next, the Veteran was afforded a May 2021 VA GERD examination with medical opinion as part of the series of VA examinations. The VA examiner performed a complete physical examination with a VA esophageal conditions Disability Benefits Questionnaire (DBQ). The Veteran recounted that he had a five year history of GERD related complaints. He denied GERD during service. The VA examiner also documented in part, "Veteran reports not being seen or treated for GERD related complaints and denied taking any medication that would cause GERD. The 12/2020 IHP is reviewed and appreciated. Sinusitis does not cause GERD and sinusitis complaints are not consistent with GERD complaints." Next, the May 2021 VA examiner went on to render a set of negative nexus opinions for all theories of direct and secondary service connection. In support of the negative nexus opinions, the VA examiner reasoned: Veteran reports 5 year hx of GERD related complaints. Veteran denies any hx of GERD during service. Complains of pyrosis every other day and reflux 2 times a week. Reports trigger foods are any fried foods. Veteran also reports a long hx of tobacco use, ETOH and caffeine use. Veteran also reports eating shortly prior to bedtime as a contributing factor regarding GERD. Regarding the lay report of chronic NSAID use during and post service. Available DTRs do not support chronic NSAIDs use during service. Veteran has multiple risk factors for GERD including tobacco use, ETOH use and caffeine use all of which can decrease lower esophageal sphincter tone increasing GERD related complaints. There is no evidence of aggravation of GERD or hiatal hernia due to SC conditions or treatment for SC conditions. Reasonably speaking, hiatal hernia is a process of natural aging and a major known cause for GERD. No functional limitations. Additionally, the VA examiner rendered a negative nexus opinion that implicitly encompasses all theories of secondary service connection, including proximate cause and aggravation. The VA examiner sympathetically reviewed the December 2200 IHP. He responded: Sinusitis does not cause GERD or Hiatal Hernia and sinusitis complaints are not consistent with GERD complaints. Veteran has multiple risk factors for GERD including tobacco use, ETOH use and caffeine use all of which can decrease lower esophageal sphincter tone increasing GERD related complaints. There is no evidence of aggravation of GERD or hiatal hernia due to SC conditions or treatment for SC conditions. Reasonably speaking, hiatal hernia is a known cause for GERD. No functional limitations. The August 2021 IHP does not identify any errors with the most recent VA examination. The Veteran contends that he is entitled to service connection for GERD. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). He is competent to report his eating and drinking schedule, and experiencing esophageal discomfort. The Veteran is also competent to relate what he has been told by a professional. He is competent to report when he began receiving treatment for GERD, and when it was first identified by physicians. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran's own lay opinions as to the diagnosis and cause of GERD are not probative evidence, although the Veteran's observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran has medical expertise, the Veteran's lay opinion beyond a description of his symptoms is of limited probative value. The most probative evidence is the contemporaneous treatment records, including the STRs, and the opinion of the May 2021 VA examiner. First, the separation examination is clinically normal for the abdomen and viscera, mouth and throat, and lungs and chest. In the related Report of Medical History, the Veteran denied frequent indigestion and stomach, liver, or intestinal trouble. By way of the Veteran's own lay history, he experienced GERD impairment since about five years prior to the May 2021 VA examination. This is generally consistent with the contemporaneous treatment records, showing the relatively recent onset of GERD, many years removed from separation. For example, a January 30, 2018 VA Primary Care Note shows in part, "GERD on omeprazole that controls symptoms." Thus, the first documentation of the Veteran having GERD by way of the Veteran's own lay history was more than two decades removed from separation. The Board assigns substantial probative weight to the contemporaneous treatment records. Second, the Board also assigns substantial probative weight to the comprehensive opinion of the May 2021 VA examiner. The VA examiner reviewed the entire claims file, considered the Veteran's lay history, and provided detailed reasons and bases. The VA examiner concluded in part: Regarding the lay report of chronic NSAID use during and post service. Available DTRs do not support chronic NSAIDs use during service. Veteran has multiple risk factors for GERD including tobacco use, ETOH use and caffeine use all of which can decrease lower esophageal sphincter tone increasing GERD related complaints. There is no evidence of aggravation of GERD or hiatal hernia due to SC conditions or treatment for SC conditions. Reasonably speaking, hiatal hernia is a process of natural aging and a major known cause for GERD. No functional limitations. The negative nexus opinions implicitly encompass all theories of direct, presumptive, and secondary service connection, including proximate cause and aggravation. There is no other positive nexus to any sinusitis, NSAIDs, or other reported medication. The VA examiner based the conclusions upon his medical expertise and a review of the contemporaneous treatment records. The addressed the Veteran's lay contentions in the lengthy reasons and bases sections, which we incorporate by reference. Therefore, we assign substantial probative weight to the May 2021 VA examination with medical opinion. Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. GERD was not manifest in service or within one year from separation, and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report that he had a remote diagnosis of GERD, the Veteran's own lay opinion regarding identifying a potential chronic disease entity, such as GERD, pales in probative weight when compared to the objective medical evidence of record. Although the Veteran takes medication and has diagnosed GERD from years after in service, such does not establish a longstanding history of this impairment. The VA examiner cited other factors. Additional causal evidence against the claim, and while not dispositive, is the lapse of so many years between discharge and the first documented medical complaints of GERD. Indeed, the Veteran's own lay history also places the onset of GERD over two decades after discharge. This multi-year gap after service provides highly probative evidence against these claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (indicating that "evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the [V]eteran's health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service"). An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the contemporaneous treatment records, and May 2021 medical opinion does not demonstrate such continuity. The May 2021 VA examiner described the Veteran's medical history showing the remote onset of the claimed disease entity several years after separation. This was based in part based upon the Veteran's own lay reporting. Once again, while not competent to diagnose GERD, he is competent to report a recent history of esophageal pain and what he has been told by his physician. Next, it appears the Veteran's theory of entitlement to service connection for GERD is also one of secondary service connection. More specifically, he contends that GERD is secondary to his service-connected chronic sinusitis, related medication including NSAIDs, and functional impairment. 38 C.F.R. § 3.310. The Board has considered the evidence of record, and finds that a GERD is not related to service, and is less likely than not proximately due to, the result of, or aggravated by any service connected disability. Indeed, the May 2021 VA examiner rendered a negative nexus opinion implicitly encompassing all theories of secondary service connection. The VA examiner considered the Veteran's theory of medications taken for chronic sinusitis and other disabilities. He noted other multiple risk factors for GERD, unrelated to service or service-connected disease or injury. This is relatively consistent with the negative findings of the May 2021 VA examiner. The VA examiner directly addressed, "The 12/2020 IHP is reviewed and appreciated. Sinusitis does not cause GERD or Hiatal Hernia and sinusitis complaints are not consistent with GERD complaints." These findings are based upon the examiner's medical expertise. There is no other competent and probative evidence establishing a positive nexus under any theory of secondary service connection. His negative nexus opinions are generally consistent with the previous December 2019 VA examination results. Therefore, service connection based upon a secondary theory of entitlement is not warranted. In short, the most probative evidence is the clinically normal STRs upon discharge and May 2021 VA examination with medical opinions. The most probative evidence establishes a remote onset of esophageal and stomach pathology several years after discharge. The VA examiner rendered negative nexus opinions for all theories of entitlement. We have found these to be the most probative evidence of record. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. There is also no nexus to chronic sinusitis or other service-connected disability. 38 C.F.R. § 3.310. Regarding any claimed relationship to NSAID use, and we note other factors described by the May 2021 VA examiner. Additionally, we considered Saunders for all theories of entitlement. There is no probative evidence to the contrary. There is no doubt to resolve. Therefore, service connection for GERD is not warranted. 6. Entitlement to service connection for hypertension, to include as secondary to service connected chronic sinusitis. The Board incorporates its discussion from the sections above by reference. "Hypertension" refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 mm Hg systolic and 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic as reflective of hypertension. See Dorland's Illustrated Medical Dictionary, 896 (32nd ed. 2012). Similarly, for VA rating purposes, the term "hypertension" means that the diastolic blood pressure is predominantly 90 mm Hg or greater. The term "isolated systolic hypertension" means that the systolic blood pressure is predominantly 160 mm Hg or greater with a diastolic blood pressure of less than 90 mm Hg. See 38 C.F.R. § 4.104, DC 7101, Note (1). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. Hypertension is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). By way of background, the Report of Medical Examination from separation disclosed a clinically normal evaluation of the heart, vascular system, and sinuses. In the related Report of Medical History, the Veteran denied high or low blood pressure. He listed his health and medications as "Good- no." Next, VA treatment records from as early as August 20, 2004 consistently show a diagnostic impression of hypertension. Years later, a January 30, 2018 VA Primary Care Note shows, "Hypertension: well controlled, restart losartan, d/c HCTZ, low sodium diet." The February 2019 IHP shows, "Hypertension and neuropathies are known complications of apnea." This assertion is not attributed to any particular medical source or examiner's findings as they relate to this Veteran. Next, the Veteran was afforded a December 2019 VA medical examination. The VA examiner reviewed the entire claims file and performed a physical examination. There are separate medical opinion documents for this condition. The VA examiner rendered a negative nexus opinion for direct and presumptive service connection. She cited the remote onset of the disease entity 17 years after separation. The VA examiner indicated, "THE CLAIMED CONDITION IS LESS LIKELY THAN NOT (less than 50 percent probability) PROXIMATELY DUE TO OR THE RESULT OF THE VETERAN'S SERVICE CONNECTED CONDITION." The VA examiner also opined that hypertension was not aggravated beyond its natural progression. The VA examiner reasoned: While NSAID use can lead to higher blood pressure, unable to determine chronic NSAID use within current available medical records. The conditions of groin rash, pes planus, hammer toes, degenerative arthritis and hallux valgus of bilateral feet, limitation of flexion of bilateral knees, tinea pedis, bilateral knee strain, nasal deviation, residuals of fracture nose, chronic sinusitis, hemorrhoids, and pseudofolliculitis barbae are not known causes or risk factors for the development or aggravation of HTN. Therefore the current condition of HTN is less likely as not aggravated beyond its natural progression due to or the result of SC conditions. Next, in the December 2020 IHP, the Veteran through his representative challenges the adequacy of the December 2019 VA examination with medical opinion. They cite changes in blood pressure during service, including readings at separation showing a "pre-hypertensive phase." The Veteran also avers: It is important to note that this veteran has chronic sinusitis and repeatedly took over the counter (OTC) medication to treat this long term disability in addition to the long history of the NSAID's this veteran took for his other conditions. The previous C&P's do not appear to take this veteran's sinusitis disability into play when determining a nexus between military service to present day with regards to this veteran's diagnosis of HTN. The examiner from the 2019 C&P also used the lack of medical documentation from the period of discharge to 2003 as a reason to provide a negative opinion. In addressing these contentions, the Veteran was afforded a new May 2021 VA hypertension examination with medical opinion. The VA examiner elicited a lay history from the Veteran, reviewed the entire claims file, and performed a physical examination. The VA examiner documented the Veteran's relevant medical history and medication regimen. Next, the VA examiner rendered a comprehensive set of negative nexus opinions encompassing all theories of direct and presumptive service connection. For direct and presumptive service connection, the VA examiner reasoned in part, "Veteran reports hx of hypertension for at least 10 years. Veteran reports not being tx for hypertension during service. No end organ pathology. Veteran denies taking any medication during active service that would elevate his blood pressure or any medication for treatment of hypertension during active service." Turning to secondary service connection, the VA examiner rendered a negative nexus opinion implicitly encompassing all theories of proximate cause and aggravation. The VA examiner explained: Review of available STRs Reenlistment physical 3/22/1983 BP 100/70. ETS physical 10/14/1986 BP 132/70, 136/70, 130/68. 6/15/1984 BP 90/68. 2/8/1985 BP 100/66. 2/12/1986 BP 104/88. 6/1/1979 BP 90/56. 8/18/1986 BP 120/80. The 12/2020 IHP, 10/2015 hearing transcript page 28 are reviewed and appreciated. Veteran denies taking any sinus related medication during service. Veteran denies taking any anti-hypertensive medication during service. Review of available STRs are negative for sinus medication, or any other medication that would affect the veterans blood pressure. Review of after service medical record 11/5/2003 43 y/o new pt appt. Told BP elevated on recent employment physical. BP 140/100. Dx: HTN. Start HCTZ 25 mg. Review of available STRs reveal no evidence of hypertension during active service. Veteran was not diagnosed until 2003, 17 years after leaving service. There is no evidence of aggravation of the veteran hypertension by any service connected condition or treatment for any service connected condition. No functional limitations. The August 2021 IHP contains, "no specific comments on the first nine issues listed in the caption..." The Veteran contends that he is entitled to service connection for hypertension. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to relate what he has been told by a professional. He is competent to report when he began receiving treatment for hypertension, and when it was first identified by physicians. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran's own lay opinions as to the diagnosis and cause of hypertension are not probative evidence, although the Veteran's observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran has medical expertise, the Veteran's lay opinion beyond a description of his symptoms is of limited probative value. The most probative evidence is the contemporaneous treatment records, including the STRs, and the opinion of the May 2021 VA examiner. First, the separation examination is clinically normal for the vascular system, heart, and sinuses. The Veteran denied high or low blood pressure at separation. Decades later, in late 2003 and into 2004, the Veteran was told that he had elevated blood pressure. He began medication. Thus, the first documentation of the Veteran having hypertension was almost two decades removed from separation. The Board assigns substantial probative weight to the contemporaneous treatment records. Second, the Board also assigns substantial probative weight to the comprehensive opinion of the May 2021 VA examiner. The VA examiner reviewed the entire claims file, and provided detailed reasons and bases. The VA examiner concluded in part, "Review of available STRs reveal no evidence of hypertension during active service. Veteran was not diagnosed until 2003, 17 years after leaving service. There is no evidence of aggravation of the veteran hypertension by any service connected condition or treatment for any service connected condition. No functional limitations." The VA examiner emphasized that the separation examination is devoid of cardiovascular pathology. The VA examiner also cited that the Veteran denied related medication. The negative nexus opinion implicitly encompasses all theories of direct, presumptive, and secondary service connection, including proximate cause and aggravation. There is no other positive nexus to any sinusitis or claimed medication. The VA examiner based the conclusions upon his medical expertise and a review of in-service blood pressure readings. He also considered the Veteran's lay history. Therefore, we assign substantial probative weight to the May 2021 VA examination with medical opinion. Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. Hypertension was not manifest in service or within one year from separation, and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report that he had a remote diagnosis of hypertension, the Veteran's own lay opinion regarding identifying a potential chronic disease entity, such as cardiovascular renal disease, pales in probative weight when compared to the objective medical evidence of record. Although there are some notations of high blood pressure identified years after in service, these do not establish a longstanding history of this impairment. The VA examiner cited blood pressure readings and records to the contrary. We note that a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the contemporaneous treatment records and May 2021 medical opinion does not demonstrate such continuity. The May 2021 VA examiner described the Veteran's medical history showing the remote onset of the claimed disease entity several years after separation. Next, it appears the Veteran's theory of entitlement to service connection for hypertension is also one of secondary service connection. More specifically, he contends that hypertension is secondary to his service-connected chronic sinusitis and related medication. 38 C.F.R. § 3.310. The Board has considered the evidence of record, and finds that a hypertension is not related to service, and is less likely than not proximately due to, the result of, or aggravated by any service connected disability. Indeed, the May 2021 VA examiner rendered a negative nexus opinion implicitly encompassing all theories of secondary service connection. The VA examiner considered the Veteran's theory of medications taken for chronic sinusitis and other disabilities. He cited the absence of medications that would cause hypertension in service. "There is no evidence of aggravation of the veteran hypertension by any service connected condition or treatment for any service connected condition. No functional limitations." In reaching this conclusion, the examiner applied his medical expertise. The negative nexus opinion is generally consistent with the conclusions of the December 2019 VA examiner. There is no other probative evidence establishing a positive nexus to sinusitis or any medication. Therefore, service connection based upon a secondary theory of entitlement is not warranted. In short, the most probative evidence is the clinically normal STRs upon discharge and May 2021 VA examination with medical opinions. This evidence establishes the remote onset of cardiovascular-renal pathology several years after discharge. The VA examiner rendered negative nexus opinions for all theories of entitlement. We have found these to be the most probative evidence of record. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. There is also no nexus to chronic sinusitis, related medication, or other service-connected disability. 38 C.F.R. § 3.310. Additionally, we considered Saunders for all theories of entitlement. There is no probative evidence to the contrary. There is no doubt to resolve. Therefore, service connection for hypertension is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching these conclusions, the Board finds that the preponderance of the evidence is against the claims. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND In light of the Veteran and his representative's contentions, a remand is necessary to ensure that the Veteran is afforded due process, and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and claimed as a major depressive disorder (MDD), with anxiety, bad dreams, and night sweats is remanded. 2. Entitlement to service connection for tension headaches, to include as secondary to an acquired psychiatric disorder is remanded. The Board incorporates its discussion from the sections above by reference. A remand is necessary for additional development in light of argument submitted by the Veteran and in compliance with the Board's April 2019 remand directives. These directives included obtaining a VA psychiatric examination. VA has also not conceded one of the claimed stressors based on in-service personal assault. A remand is still necessary to attempt to corroborate all of the claimed in service stressors, and then to obtain a VA examination that complies with the April 2019 remand directives. By way of history, at the October 2015 hearing, the Veteran provided detailed accounts of several confrontations with noncommissioned officers in service, and alleged that such caused or contributed to his psychiatric symptoms. In particular, he described feeling derepressed and being assaulted in service. See October 2015 Hearing Transcript, pp. 25-27. Regarding headaches, he described, "Uh, that I (inaudible) tension headaches from the stress, um, you know, the, I guess the anger inside for how I was treated, which, you know, I guess it just, it's gonna follow me. It could be in my head, you know, and I, uh, think one reason why I mean to be short patient with people, uh, I look at how people treat me. So uh, I guess I worry a lot and, uh, and, um, cause a lot of unnecessary stress on myself." Id. at p. 30. Second, the February 2016 remand directives required the VA examiner to consider, "The stressful events described by the Veteran at the October 2015 hearing, and their adequacy to support a psychiatric diagnosis, must be discussed. The examiner must comment on the presence of headaches as a psychiatric/stress symptom, and discuss whether the occurrence of such in service represents the onset of a chronic psychiatric or headache condition." A private treatment record from Alabama Clinics, received by VA in March 2016 shows a mental status examination with a diagnosis of bipolar disorder. Next, the June 2016 VA psychiatric examination shows that the Veteran does not meet the criteria for PTSD. The VA examiner identified unspecified bipolar-type disorder, cocaine use disorder in early remissions, cannibis use disorder in early remission, and alcohol use disorder in early remission. The VA examiner rendered a negative nexus opinion and noted substance abuse issues. However, it did not fully address the Veteran's hearing testimony, as required by the remand directives. It shows that the Veteran's stressor is related to personal assault. The VA psychologist ultimately opined in part, "In addition, he cited only a few of the symptoms necessary for a PTSD diagnosis. In light of above-noted considerations, the examiner cannot assert [the Veteran] as likely as not (at least 50/50 probability) suffers from PTSD (DSM-V) or other psychiatric disorders that are caused by or a result of military service." The following year, the Veteran submitted an August 2017 VA Form 21-0781, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD). In it, he provides two new detailed accounts of personal assault in service. The first involves being punched and breaking his nose while in Germany. The second involves a live fire heavy artillery field exercise, and being pushed/punched so hard that it knocked the wind out of him. There is also a description of being "in shock" because the Veteran could not sleep due to fear of exploding Howitzer bombs, grenades, mortar, and gunfire, all night long for one to two weeks. The February 2019 IHP shows in part, "He also first complained of depression in service and went to the mental health clinic as well." The Veteran contends that he is entitled to service connection for PTSD, and that he carries a diagnosis. He cites the ongoing VA treatment records, combined with lay and corroborating historical evidence, in support of his claim. With regard to the Veteran's report of being struck in the nose on May 29, 1984 in service, the Board conceded this in-service stressor in April 2019. The crucial remaining issue is whether there is a nexus between the Veteran's current psychiatric disability and this stressor. In addition, the Board observes that the current record does not contain independent or objective documentation that corroborates or verifies the Veteran's additional two claimed in-service stressors (i.e., a hard push, and shock from live fire training). This is also significant inasmuch as the Veteran's alleged stressor is still considered non-combat in nature. See generally 38 C.F.R. § 3.304. In addition, although the evidence of record currently reflects a claimed diagnosis of psychiatric disorders other than PTSD, that diagnosis is not based on the credible stressors above and is not based on other stressors that have been able to be independently verified. For this Veteran, service connection for PTSD may not be granted in the absence of a verified stressor. If there is no combat experience, there must be independent evidence to corroborate the Veteran's statements as to the occurrence of a claimed stressor. Doran v. Brown, 6 Vet. App. 283, 288-89 (1994). A Veteran's testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor. Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of a claimed in-service stressor. Cohen v. Brown, 10 Vet. App. 128, 142 (1997); Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996). Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with § 4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). If a posttraumatic stress disorder claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a posttraumatic stress disorder claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(5). The June 2020 Supplemental Statement of the Case (SSOC) shows in part, "The available medical evidence is insufficient to confirm a link between current symptoms and an in-service stressor." This is confusing, as the Board conceded one stressor, supra. Nevertheless, the SSOC identified that an August 7, 2019 VA Form 21-0781 has not been completed and returned. The Board observes that there is returned mail in the claims file from August 10, 2020. Next, the December 2020 IHP contains considerable argument related to VA's duty to assist in developing this claim. The IHP reads in part, "This veteran has been consistent regarding his stressors: his issues with his leadership who he felt threatened him and his recurrent disciplinary problems. All of this appears to have been overlooked by the VA or rather, brushed aside as Mr. [Veteran] did not receive any treatment while in service or within one year post service. There are markers within this veteran's STR's which point to mental health concerns." In the January 2021 Remand, the Board observed that in April 2019 Remand for the claimed acquired psychiatric disorder, the Board ordered that the Veteran be provided with a new VA psychiatric examination that addresses his contentions, including those contained in the August 2017 Statement. 38 U.S.C. § 5103A (d); McLendon, Barr, both supra. The VA psychiatric examination was required to specifically discuss the nature and etiology of unspecified bipolar disorder, including a claimed onset in service as a result of personal assault. This development has not been fully completed. The December 2020 IHP reads in part, "Should the Board feel otherwise, we ask that they remand this case for further development. We also recommend that an independent medical opinion be obtained regarding this veteran's multiple mental health conditions." Significantly, the Veteran and his representative were sent February 9, March 12, and April 21, 2021 VA Subsequent Development Letters. They included a request for details of the claimed personal trauma incidents related to the PTSD claim, with an attached VA 21-0781. This form has not been completed to allow VA to continuing developing the claim. It follows that the related VA psychiatric examination for this issue has not yet been completed. For this PTSD issue, the Veteran has continued to pursue his appeal, but there is still an incomplete record upon which to decide this issue. The related examination was never scheduled and completed, although several other examinations have been conducted in 2021. As a threshold matter, the Veteran and his representative must return the VA Form 21-0781a Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault providing any additional details he wishes to be considered regarding his in-service stressors. They may also otherwise assist VA by submitting any additional medical documentation. Following receipt of this necessary evidence, the Veteran will be afforded a VA psychiatric examination in line with the original April 2019 Board Remand directives. If this evidence is not received or if the Veteran and his representative do not cooperate, the issue will be adjudicated based upon the limited evidence of record. The Board notes that the Veteran still ultimately bears some burden of production. 38 U.S.C. § 5107 (a); Cromer v. Nicholson, 455 F.3d 1346 (Fed. Cir. 2006). Pivoting to the related issue of service connection for tension headaches, the Board observes that the Veteran testified that his tension headaches are related to anger worrying, and stress. This can be construed as a claim for secondary service connection for tension headaches. By way of background, the February 2016 Remand directives required, "The examiner must comment on the presence of headaches as a psychiatric/stress symptom, and discuss whether the occurrence of such in service represents the onset of a chronic psychiatric or headache condition." Next, a February 2018 VA examination shows a diagnosis of tension headaches in February 2018. However, it also shows a history of onset back to 1985. There is no nexus medical opinion. On remand, this inconsistency should be resolved. Later, in December 2019, the Veteran was afforded a VA headaches medical opinion. The VA examiner rendered a negative nexus opinion for direct and presumptive service connection. She cited the remote onset of the disease entity 17 years after separation. The VA examiner also ultimately concluded that there was no aggravation beyond the condition's natural progression. The VA examiner reasoned, "Less likely that condition of tension headaches is aggravated beyond its natural progression. Condition is currently only treated with OTC medications." Importantly, a separate medical opinion document contains a positive nexus opinion for proximate cause for headaches. The rationale reads: Research has shown that there are strong links between tension headaches and mental disorders, including depression and anxiety. Documentation from 7/8/2009 notes claimant stating "believes his headache is related to depression problem." Documentation from 5/2/2005 notes headaches occurring when working under stress. At the October 2015 hearing, Veteran claimed having anger that caused increased stress. Therefore it is at least as likely as not that the current condition of tension headaches is at least as likely as not proximately due to or the result of SC psychiatric condition. Based upon this positive nexus opinion, the issue of service connection for tension headaches is intertwined with the ongoing requested development related to an acquired psychiatric disorder. Therefore, and consistent with the Board's approach from January 2021, this issue is also remanded to the AOJ pending the outcome of the service connection for an acquired psychiatric disorder claim. 3. Entitlement to assignment of a 10 percent evaluation under 38 C.F.R. § 3.324, based on multiple, noncompensable, service-connected disabilities, prior to August 5, 2013 is remanded. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. The Board incorporates its discussion from the sections above by reference. Consistent with its approach in February 2016 and January 2021, the Board is mindful that entitlement to these benefits is dependent upon consideration of the impact of service-connected disabilities on a Veteran's employability. The Veteran through his representative requests in the recent August 2021 Informal Hearing Presentation (IHP), "Based on our review, we submit that a further remand is necessary, particularly with regard to entitlement to TDIU." The Veteran through his representative requested an updated VA 21-8940 since 2009. They also request that VA make an attempt to obtain records from the Social Security Administration (SSA). See Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992) (where VA has actual notice of the existence of records held by SSA which appear relevant to a pending claim, VA has a duty to assist by requesting those records from SSA). It would also be premature to adjudicate either claim prior to resolution of the other issues. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Therefore, these issues are also remanded. The matters are REMANDED for the following action: 1. If the Veteran identifies other evidence, obtain updated copies of the Veteran's VA treatment records, and associate them with the Veteran's claims folder. 2. Send the Veteran a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability and VA Form 21-4192, Request for Employment Verification, to be fully completed and returned to VA. The Veteran should also submit copies of any leave and earnings statements attached to these documents. 3. Request that the Social Security Administration (SSA) provide copies of any records pertaining to the Veteran, to include any medical records obtained in connection with any applications. Any materials obtained should be associated with the Veteran's VA claims folder. 4. Inform the Veteran that he must submit an updated stressor statement on a VA Form 21-0781a Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault providing any additional details he wishes to be considered regarding his in-service stressors. If no additional evidence is received, the case will be adjudicated based upon the evidence of record. 5. Make another attempt to corroborate the Veteran's claimed in-service stressors not yet conceded of (1) being pushed so hard that it knocked the wind out of him, and (2) being in shock in service during live fire training. If more details are needed, contact the Veteran to request the information. See December 2020 Informal Hearing Presentation (IHP). 6. After the development related to PTSD based upon personal assault noted above has been completed, please schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his claimed acquired psychiatric disorder, to include PTSD, a major depressive disorder (MDD), and unspecified bipolar-type disorder. This examination must be conducted by a VA psychiatrist or psychologist. The claims file and a copy of this remand must be made available to the examiner in conjunction with the requested examination, and the examiner should indicate that the claims file was reviewed. All necessary tests should be conducted, and the Veteran's complaints should be recorded in full. The VA examiner should answer the following: (i) What are the Veteran's current psychiatric disorders? In particular, has the Veteran had PTSD, MDD, or a bipolar-type disorder at any time during the appeals period? (ii) Is it at least as likely as not (a probability of 50 percent or greater) that a diagnosed non-PTSD psychiatric disorder began in service, was caused by service, or is otherwise related to active military service? Attention is directed to private treatment records from Alabama Clinics, received by VA in March 2016, showing a diagnosis of bipolar disorder. (iii) If PTSD is diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not that the Veteran's disability is causally related to any corroborated stressor during his military service, whether a verified in-service stressor is adequate to support a diagnosis of PTSD, and whether the current PTSD symptoms relate to the stressor(s). (iv) If PTSD is diagnosed based upon the claimed in-service personal assault stressor, the examiner should provide an opinion as to whether it is at least as likely as not that the in-service personal assault occurred, and should identify the nature of the evidence used to reach that opinion. To date, the Board has conceded the stressor of in-service assault in May 1984 resulting in a nasal fracture, supra. In addressing these questions, please discuss the Veteran's lay assertions of record, to include any stressor statements submitted into evidence (e.g., August 2017 VA Form 21-0781, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD). Attention is generally invited to the Veteran's hearing testimony. See October 2015 Hearing Transcript, pp. 25-27. (v) Lastly, the examiner should comment on the impact of the service connected disabilities, individually and in combination, on the Veteran's ability to function in work-related tasks (e.g., sitting, standing, walking, bending, stooping, lifting, cognitive functioning, attendance, etc.). In rendering the requested opinions, the examiner must be aware that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a particular basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The VA examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The VA examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. It is not sufficient to base an opinion on a mere lack of documentation of complaints in the service or post-service treatment records. 7. After completing all necessary development, adjudicate the claims for entitlement to assignment of a 10 percent evaluation under 38 C.F.R. § 3.324, based on multiple, noncompensable, service-connected disabilities, prior to August 5, 2013, and a TDIU, in light of all pertinent evidence and legal authority. 8. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his representative an appropriate supplemental statement of the case (SSOC). Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Bodi, 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.