Citation Nr: 21069436 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 18-04 209 DATE: November 18, 2021 ORDER As new and material evidence has been received, the Veteran's claim to entitlement to service connection for right fingernail onychomycosis is reopened. As new and material evidence has been received, the Veteran's claim to entitlement to service connection for left fingernail onychomycosis is reopened. As new and material evidence has been received, the Veteran's claim to entitlement to service connection for right toenail onychomycosis is reopened. As new and material evidence has been received, the Veteran's claim to entitlement to service connection for left toenail onychomycosis is reopened. Entitlement to an effective date earlier than January 27, 2012 for the grant of service connection for unspecified anxiety disorder is denied. Entitlement to service connection for hyperlipemia is denied. Entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for diabetes mellitus is granted. Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities is granted. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities is granted. Entitlement to service connection for peripheral vascular disease of the lower extremities is granted. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is granted. Entitlement to service connection for a heart disability is granted. Entitlement to service connection for hypothyroidism is granted. Entitlement to service connection for hypertension is granted. Entitlement to service connection for testicular dysfunction is granted. Entitlement to service connection for right fingernail onychomycosis is granted. Entitlement to service connection for left fingernail onychomycosis is granted. Entitlement to service connection for left toenail onychomycosis is granted. Entitlement to service connection for right toenail onychomycosis is granted. Entitlement to service connection for a back disability is granted. Entitlement to service connection for a cervical spine disability is granted. Entitlement to service connection for obstructive sleep apnea (OSA) is granted. REMANDED Entitlement to an increased evaluation in excess of 30 percent for unspecified anxiety disorder is remanded. Entitlement to service connection for bilateral knee disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. An October 2016 rating decision denied service connection for the Veteran's claimed right and left fingernail and right and left toenail onychomycosis. The Veteran was notified of this decision but did not initiate an appeal, therefore the decision became final. 2. The evidence received since that decision, when considered by itself or in connection with evidence previously assembled, relates to unestablished facts necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for right and left fingernail and right and left toenail onychomycosis. 3. In a January 2018 rating decision, the Regional Office (RO) granted service connection for unspecified anxiety disorder effective January 27, 2012. 4. There is no evidence indicating a formal or informal claim for service connection for unspecified anxiety disorder prior to January 27, 2012. 5. Hyperlipidemia, to include high cholesterol, is a laboratory measurement which by itself does not constitute a recognized disability for purposes of VA benefits entitlement 6. There is a proximate balance of positive and negative evidence to show the Veteran's claimed bilateral hearing loss was related to the Veteran's service. 7. There is a proximate balance of positive and negative evidence to show the Veteran's claimed tinnitus was related to the Veteran's service. 8. There is a proximate balance of positive and negative evidence to show the Veteran's claimed diabetes mellitus was related to the Veteran's service 9. There is a proximate balance of positive and negative evidence to show the Veteran's claimed peripheral neuropathy of the upper extremities was related to the Veteran's service. 10. There is a proximate balance of positive and negative evidence to show the Veteran's claimed peripheral neuropathy of the lower extremities was related to the Veteran's service. 11. There is a proximate balance of positive and negative evidence to show the Veteran's claimed peripheral vascular disease of the lower extremities was related to the Veteran's service. 12. There is a proximate balance of positive and negative evidence to show the Veteran's claimed COPD was related to the Veteran's service. 13. There is a proximate balance of positive and negative evidence to show the Veteran's claimed heart disability was related to the Veteran's service. 14. There is a proximate balance of positive and negative evidence to show the Veteran's claimed hypothyroidism was related to the Veteran's service. 15. There is a proximate balance of positive and negative evidence to show the Veteran's claimed hypertension was related to the Veteran's service. 16. There is a proximate balance of positive and negative evidence to show the Veteran's claimed testicular dysfunction was related to the Veteran's service. 17. There is a proximate balance of positive and negative evidence to show the Veteran's claimed right fingernail onychomycosis was related to the Veteran's service. 18. There is a proximate balance of positive and negative evidence to show the Veteran's claimed left fingernail onychomycosis was related to the Veteran's service. 19. There is a proximate balance of positive and negative evidence to show the Veteran's claimed right toenail onychomycosis was related to the Veteran's service. 20. There is a proximate balance of positive and negative evidence to show the Veteran's claimed left toenail onychomycosis was related to the Veteran's service. 21. There is a proximate balance of positive and negative evidence to show the Veteran's claimed back disability was related to the Veteran's service. 22. There is a proximate balance of positive and negative evidence to show the Veteran's claimed cervical spine disability was related to the Veteran's service. 23. There is a proximate balance of positive and negative evidence to show the Veteran's claimed obstructive sleep apnea was related to the Veteran's service.. CONCLUSIONS OF LAW 1. The October 2016 rating decision, which denied the Veteran's claim of entitlement to service connection for right and left fingernail and right and left toenail onychomycosis, is final. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104, 3.156, 20.201, 20.302, 20.1103. 2. Evidence received since the October 2016 rating decision in relation to the Veteran's claim for entitlement to service connection for service connection for right and left fingernail and right and left toenail onychomycosis is new and material; therefore, the claims are reopened. 38 U.S.C. § 5108 ; 38 C.F.R. § 3.156. 3. The criteria for an effective date earlier than January 27, 2012, for the grant for service connection for unspecified anxiety disorder, have not been met. 38 U.S.C. §§ 1155, 5110, 38 C.F.R. §§ 3.400, 4.71a. 4. The criteria for entitlement to service connection for hyperlipidemia, have not been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for entitlement to service connection for bilateral hearing loss, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for entitlement to service connection for tinnitus, have not been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for entitlement to service connection for diabetes mellitus, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria for entitlement to service connection for peripheral neuropathy of the upper extremities, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 9. The criteria for entitlement to service connection for peripheral neuropathy of the lower extremities, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 10. The criteria for entitlement to service connection for peripheral vascular disease of the lower extremities, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 11. The criteria for entitlement to service connection for COPD, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 12. The criteria for entitlement to service connection for a heart disability, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 13. The criteria for entitlement to service connection for hypothyroidism, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 14. The criteria for entitlement to service connection for hypertension, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 15. The criteria for entitlement to service connection for testicular dysfunction, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 16. The criteria for entitlement to service connection for right fingernail onychomycosis, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 17. The criteria for entitlement to service connection for left fingernail onychomycosis, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 18. The criteria for entitlement to service connection for right toenail onychomycosis, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 19. The criteria for entitlement to service connection for left toenail onychomycosis, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 20. The criteria for entitlement to service connection for a back disability, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 21. The criteria for entitlement to service connection for a cervical spine disability, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 22. The criteria for entitlement to service connection obstructive sleep apnea, have been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in active-duty service with the Navy from July 1969 to December 1970 to include service in the Reserves. This matter is on appeal from rating decisions in February 2013, February 2016, and November 2018. The Veteran was afforded a June 2021 hearing before the undersigned Judge; a transcript of the hearing has been associated with the claims record. New and Material Evidence In order to reopen a claim which has been denied by a final decision, the claimant must present new and material evidence. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § § 3.156 (a). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the "credibility" of newly presented evidence is to be presumed unless the evidence is inherently incredible or beyond the competence of the witness). The language of 38 C.F.R. § § 3.156 (a) creates a low threshold for finding new and material evidence and views the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Evidence "raises a reasonable possibility of substantiating the claim," if it would trigger VA's duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). Fingernail and Toenail onychomycosis An October 2016 rating decision denied entitlement to service connection for fingernail and toenail onychomycosis. Evidence available at the time of the decision included the Veteran's service treatment records (STRs) and medical treatment records. The rating decision found no record in the Veteran's STRs for complaints, treatments or diagnoses for fingernail or toenail onychomycosis. New evidence since that decision includes VA medical treatment records; submitted lay statements and testimony; VA and private examination; and the Veteran's substantive appeal. The Veteran has stated that his fingernail and toenail onychomycosis were related to chemical or toxin exposure during his active-duty service. The evidence and statements, if presumed credible, raise a reasonable possibility of substantiating the claim. Therefore, new and material evidence has been received, and the claims for entitlement to service connection for fingernail and toenail onychomycosis, is reopened. See Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Effective Dates The applicable law and regulations concerning effective dates state that, except as otherwise provided, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110 (a) (2012); 38 C.F.R. § 3.400 (2018). An exception to this rule exists under 38 C.F.R. § 3.400 (o)(2). This provision allows VA to assign an effective date for increased rating up to one year prior to the date of claim where medical evidence indicates an increase in disability during that time period. In cases involving direct service connection, the effective date will be the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service. 38 C.F.R. § 3.400 (b)(2)(i). VA amended its adjudication regulations on March 24, 2015, to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments, however, are only effective for claims and appeals filed on or after March 24, 2015. Under the old regulations, any communication or action, indicating an intent to apply for one or more benefits under laws administered by VA, from a claimant or the claimant's representative, may be considered an informal claim. Such informal claim must identify the benefit sought. 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 one 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. 38 C.F.R. § 3.155 (a) (in effect prior to March 24, 2015). There is no set form that an informal written claim must take. All that is required is that the communication indicates an intent to apply for one or more benefits under the laws administered by VA, and identify the benefits sought. Rodriguez v. West, 189 F.3d 1351 (1999). Case law is clear that this means the claimant must describe the nature of the disability for which he is seeking benefits, such as by describing a body part or symptom of the disability. Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter before the Board, the benefit of the doubt will be granted to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7 (2018); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on the merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Unspecified anxiety disorder The Veteran seeks an earlier effective date for the grant of service connection for unspecified anxiety disorder effective January 27, 2012, the date the Veteran submitted his claim. After review of the evidence of record, the Board finds an earlier effective date is not warranted for the grant of service connection for the Veteran's unspecified anxiety disorder. The Veteran applied for service connection for his unspecified anxiety disorder on January 27, 2012. A January 2018 rating decision granted service connection effective January 27, 2012, the date the Veteran filed his claim. A review of the Veteran's claims file finds no evidence indicating a formal or informal claim for unspecified anxiety disorder prior to January 27, 2012. The Veteran did not assert a claim seeking benefits for symptoms of his unspecified anxiety disorder, nor did he make a general statement of an intent to seek service connection for disabilities occurring during active-duty service that were reasonably identifiable in his service treatment records. See Sellers v. Wilkie, No. 16-2993, 2018 U.S. App. Vet. Claims LEXIS 1114 (Vet. App. Aug. 23, 2018) (holding that an informal claim for benefits may be raised where a claimant makes a general statement of intent to seek benefits for unspecified disabilities and there is evidence of reasonably identifiable in-service diagnoses in service treatment records in the possession of the RO). The Veteran filed his claim for service connection for his unspecified anxiety disorder condition on January 27, 2012, which is not within one year of his separation from service in December 1970. The Veteran and his representative have not set forth any substantive arguments that an earlier effective date is warranted for his heart condition, nor contend what the effective date they are seeking for his condition. At the June 2021 hearing, the Veteran's representative asserted that the January 27, 2012 date was the correct date and that they were not seeking an earlier effective date. The Board finds the January 27, 2012 claim for service connection for the Veteran's unspecified anxiety disorder is "later" than any entitlement may have arisen, and therefore is the appropriate effective date. The Board notes that in a submitted March 2018 private mental disabilities benefits questionnaire (DBQ), the private provider opined that the Veteran's anxiety had been long standing issue for many years. The Board notes that VA shall construe any communication or action from a Veteran indicating intent to apply for one or more benefits as an informal claim. For any informal claim received prior to March 24, 2015, VA is required to identify and act on such claims, provided such a claim identifies the benefit sought. 38 U.S.C. § 5110 (b)(3); 38 C.F.R. §§ 3.1 (p), 3.155(a). VA is not required to anticipate any potential claim for a particular benefit where no intention to raise it was expressed. See Brannon v. West, 12 Vet. App. 32, 35 (1998) (holding that before VA can adjudicate a claim for benefits, the claimant must submit a written document identifying the benefit and expressing some intent to seek it). The Board notes that medical evidence alone cannot be an informal claim; there must be intent to apply for a benefit. Brannon, 12 Vet. App. at 35. VA's possession of medical evidence showing a particular diagnosis or causal connection may not provide a basis for the assignment of an earlier effective date. The effective date for an award of service connection is not based on the earliest medical evidence demonstrating a causal connection, but on the filing date of the application upon which service connection was eventually awarded. Lalonde v. West, 12 Vet. App. 377, 382 (1999); see McGrath v. Gober, 14 Vet. App. 28 (2000). Here, while the March 2018 private examination reported symptoms for many years prior to the January 27, 2012 date, the evidence of record does not show any intent to file a claim or application for service connection for unspecified anxiety disorder until January 27, 2012. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. The Board finds the preponderance of the evidence is against the Veteran's claim for effective date earlier than January 27, 2012 for unspecified anxiety disorder. As such, that doctrine is not applicable in the appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 ; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service Connection Generally, service connection is warranted when a claimant shows: "(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 the so-called 'nexus' requirement." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). Also, a disability that is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 ; Allen v. Brown, 7 Vet. App. 439 (1995). To prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When determining service connection, all theories of entitlement, direct and secondary, must be considered if raised by the evidence of record, applying all relevant laws and regulations. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). When evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility and probative value of proffered evidence in the context of the record as a whole. See Evans v. West, 12 Vet. App. 22, 26 (1998). The Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. 38 U.S.C. § 5107 (b); See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Hyperlipemia The Veteran contends that he is entitled to service connection for hyperlipidemia, also known as high cholesterol. Symptoms or clinical findings, such as laboratory findings, are not disabilities within the law. Absent evidence of a current disability, a claim for service connection must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Veteran's hyperlipidemia represents only a laboratory finding and is not a disability for which VA compensation benefits are payable. See 61 Fed. Reg. 20440, 20445 (May 7, 1996) (diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results rather than disabilities and are therefore not appropriate entities for the rating schedule to address). The evidence of record does not identify or suggest underlying diseases to which the claimed symptoms or laboratory findings may be related. Service connection for hyperlipidemia must be denied in the absence of a current disability for VA purposes. Bilateral hearing loss and tinnitus The Veteran asserts his bilateral hearing loss and tinnitus are related to his active-duty service. Service connection for chronic diseases listed in 38 U.S.C. sections 1101 (3) and 38 C.F.R. § 3.309 (a), such as bilateral sensorineural hearing loss, may be established on a presumptive basis if the chronic disease was shown as chronic in service; manifested to a compensable degree within a presumptive period, usually one year, after separation from service; or was noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303 (b), 3.307, 3.309(a). For VA purposes, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels (dB) or greater, the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, and 4000 Hz are 26 dB or greater, or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran was afforded a September 2018 VA examination. The Veteran's puretone thresholds were measured as followed: HERTZ 1000 2000 3000 4000 AVG RIGHT 35 40 45 40 40 LEFT 35 35 40 50 40 Maryland CNC testing was 60 percent for the right ear and 60 percent for the left ear. As such, the Board finds the Veteran with current hearing loss. The Veteran also reported experiencing tinnitus that comes and goes on a daily basis. The Board notes that the Veteran is competent to identify tinnitus by its observable manifestations, as such condition is readily observable and does not require medical expertise to establish its existence. See Charles v. Principi, 16 Vet. App. 370 (2002). Accordingly, the Board also finds the Veteran with a current diagnosed disability for tinnitus. Review of the Veteran's service treatment records (STRs) do not show complaints, treatment or diagnosis relating to bilateral hearing loss or tinnitus. In January 2015 the Veteran reported serving as a boiler repairman in service. In an April 2015 statement, the Veteran stated that he was exposed to loud noises in service from working with air hammers, needle guns and other noises while working on the boilers; the Veteran indicated that he "worked on." The Veteran was afforded November 2017 and September 2018 VA examinations. The examiners opined that the Veteran's hearing loss and tinnitus were less likely than not related to the Veteran's service because there was nothing in the Veteran's STRs and the Veteran did not report or was diagnosed with hearing loss until many years after his separation from service. At the Veteran's June 2021 hearing, the Veteran was accompanied by a private provider who testified that the Veteran's exposure to loud noises from tools such as needle guns in service could result in later manifestations of hearing loss years afterwards. The Board notes the November 2017 and September 2018 VA examiners found it less likely than not that the Veteran's hearing loss and tinnitus were related to his service because of no complaints or diagnoses of hearing loss or tinnitus in service; However, the examiners did not consider or address the Veteran's statements in April 2015 and June 2021 hearing testimony concerning noise exposure from tools and working with the boilers or explain why such statements were not considered in their opinions. As such, the Board finds the opinions inadequate and afforded less probative value. The Board also notes the absence of in-service evidence of a hearing disability during service (i.e., one meeting the requirements of 38 C.F.R. § 3.385) is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service (as opposed to intercurrent causes). See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). The Board finds there is sufficient evidence to support a link between the Veteran's diagnosed bilateral hearing loss and tinnitus, and his acoustic trauma in service, despite the examiners' findings. As such, in light of the Veteran's report of acoustic trauma in service, the current diagnosis of hearing loss and tinnitus, and the provider's testimony regarding the manifestation of symptoms from noise exposure years after service, the Board finds the evidence is at least in equipoise. As such, the benefit of the doubt is resolved in the Veteran's favor and service connection for hearing loss and tinnitus is warranted. Diabetes Mellitus (DM); peripheral neuropathy of the upper and lower extremities; peripheral vascular disease of the lower extremities; chronic obstructive pulmonary disease (COPD); heart disability; hypothyroidism; hypertension; testicular dysfunction; right and left fingernail onychomycosis; right and left toenail onychomycosis; back disability; cervical spine disability; and obstructive sleep apnea The Veteran asserts his diabetes mellitus (DM); peripheral neuropathy of the upper and lower extremities; peripheral vascular disease of the lower extremities; chronic obstructive pulmonary disease (COPD); heart disability; hypothyroidism; hypertension; testicular dysfunction; right and left fingernail onychomycosis; right and left toenail onychomycosis; back disability; cervical spine disability; and obstructive sleep apnea are related to his service. Review of the medical treatment record to include submitted VA and private examinations show diagnoses and treatment for the Veteran's claimed issues. A December 2003 sleep study diagnosed the Veteran with sleep apnea. Accordingly, the Board finds the Veteran with a current disability. Review of the Veteran's service treatment records do not show complaints, treatments or diagnoses for the Veteran's claimed issues. In submitted November 2012 private provider statements, the providers indicated the Veteran reported exposure to many chemicals during his service without safety or respiratory equipment; the providers opined that such exposure may have or more than likely caused the Veteran's current medical issues. The Board notes that the statements did not specify which particular medical disability was a result of the Veteran's reported chemical exposure or cite to specific record or rationale to explain their findings. The Veteran has submitted statements and testimony regarding the nature and etiology of his claimed issues. In submitted notice of disagreement (NOD), the Veteran reported that in the Navy he was assigned to the ship's boiler room along with his brother where he was exposed to many chemicals. The Veteran stated that he and his brother suffered from the same health conditions. The Veteran has also submitted articles discussing the relationship between chemicals and his claimed issues on appeal. The Veteran was afforded February 2014, September 2018 and January 2020 VA examinations regarding the nature of his claimed issues. The Veteran has also submitted private opinions in June2018, July 2018, and September 2018 in support of his appeal. The Board also notes that the private provider who provided the 2018 opinions appeared at the June 2021 hearing and testified to the relationship between the Veteran's chemical exposure in service and his appealed issues. The provider indicated that he reviewed medical literature and that chemical exposure could easily damage the body tissue or disrupt the endocrine system and therefore result in the Veteran's current medical issues. After considering the evidence of record, the Board finds that there is an approximate balance of positive and negative evidence and opinions concerning the nature and etiology of the Veteran's claimed issues and at least in equipoise. As such, the Board the benefit of the doubt is resolved in the Veteran's favor and a grant of service connection for diabetes mellitus (DM); peripheral neuropathy of the upper and lower extremities; peripheral vascular disease of the lower extremities; chronic obstructive pulmonary disease (COPD); heart disability; hypothyroidism; hypertension; testicular dysfunction; right and left fingernail onychomycosis; right and left toenail onychomycosis; back disability; cervical spine disability; and obstructive sleep apnea is warranted. The Board acknowledges the Veteran has asserted alternative theories of entitlement for service connection to include secondary theories, exposure to asbestos and exposure to herbicides. However, as the theory of service connection is applicable for the Veteran's claimed issues, the Board finds it is not necessary to address the Veteran's raised alternative theories of entitlement. REASONS FOR REMAND The Board finds that remand is warranted for additional development. Regarding the evaluation of the Veteran's unspecified anxiety disorder, the most recent VA examination evaluating the severity of the Veteran's psychiatric disorder was held in May 2018. The Board notes that a March 2018 private mental DBQ shows the provider finding the Veteran with 100 percent impairment; however, the provider does not provide specific rationale or reference to specific findings to support the reported severity of impairment. As such, the Board finds the March 2018 private mental DBQ inadequate and affords it less probative value. At the Veteran's June 2021 hearing, the Veteran's representative testified that in the past 10 years the Veteran's symptoms have worsened to include declining attention and concentration. While the Board is not required to direct a new examination simply due to the passage of time, a new examination is appropriate when the claimant asserts that the disability in question has undergone an increase in severity since the last examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Given the Veteran's statements and testimony that his unspecified anxiety disorder has worsened, the Board finds that a remand is warranted to ascertain the current severity of his condition. Regarding the Veteran's claim for bilateral knee disability, the Board notes that review of the claims record does not show a VA examination has been held to ascertain the nature and etiology in relation to the Veteran's service; therefore remand is also warranted to obtain an examination. As the Veteran's TDIU claim is inextricably intertwined with the remanded increased rating and service connection claim, the TDIU issue is also remanded. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated and outstanding treatment records. 2. Schedule the Veteran for a VA examination to ascertain the current severity and manifestations of the Veteran's unspecified anxiety disorder. The examiner should carefully consider the Veteran's lay statements regarding his condition and the effects on his occupational and social functioning. 3. Schedule a VA examination with an appropriate provider to determine the nature and etiology of the Veteran's bilateral knee disability. The complete record, to include a copy of this remand, must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. The VA examiner should opine as to the following: (a.) Identify each current bilateral knee disability. If any disability existed during the appeal period to the present but has resolved, this should be made clear. (b.) The examiner should record in detail the Veteran's history of his bilateral knee disability and how they affect his ability to function. (c.) For any diagnosed bilateral knee disability, is it at least as likely as not (50 percent probability or greater) the disability had its onset during, was caused by, or is otherwise related to active service? (d.) The examiner is advised that the Veteran is competent to report in-service events and treatment, and the Veteran's symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. (e.) If the examiner cannot provide the above opinions, the examiner is advised that he/she must explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed, such as additional records and/or diagnostic studies). (f.) If the examiner cannot provide an answer because further information is needed to assist in making the determination, all reasonable steps to obtain the missing information should be exhausted before concluding that the answer cannot be provided. (g.) The opinions should include a discussion of any pertinent studies or medical literature, as well as pertinent evidence on file. (h.) If the VA examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner's medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. A clearly stated rationale for any opinion offered should be provided. 4. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Yang, Attorney-Advisor 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.