Citation Nr: 21069437 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 18-47 057 DATE: November 18, 2021 ORDER Prior to June 10, 2019, an initial disability rating in excess of 50 percent for pervasive depressive disorder is denied. Since June 10, 2019, a disability rating of 70 percent, but no higher, for pervasive depressive disorder is granted. Service connection for a left arm disability is denied. Service connection for a right arm disability is denied. Service connection for a respiratory disability is denied. Service for a gallbladder disability is denied. Service connection for a thyroid disability is denied. Service connection for a left hand disability is denied. Service connection for a right hand disability is denied. Service connection for a left hip disability is denied. Service connection for a right hip disability is denied. As new and material evidence sufficient to reopen the previously denied claim for service connection for diabetes mellitus has been received, the application to reopen is granted. As new and material evidence sufficient to reopen the previously denied claim for service connection for Hepatitis C has been received, the application to reopen is granted. REMANDED Service connection for a disability of the eyes is remanded. Service connection for hypertension is remanded. Service connection for pancreatitis is remanded. Service connection for a neurological disability of the left upper extremity is remanded. Service connection for a neurological disability of the right upper extremity is remanded. Service connection for a neurological disability of the left lower extremity is remanded. Service connection for a neurological disability of the right lower extremity is remanded. Service connection for diabetes mellitus is remanded. Service connection for Hepatitis C is remanded. A total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to June 10, 2019, the Veteran's pervasive depressive disorder was not manifested by occupational and social impairment, with deficiencies in most areas, such as school, family relations, judgment, or thinking due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; or an inability to establish and maintain effective relationships. 2. Since June 10, 2019, the Veteran's pervasive disorder has been manifested by occupational and social impairment, with deficiencies in most areas, such as work, thinking, and mood, due to such symptoms as: near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. 3. The Veteran's left arm disability is not attributable to service and arthritis of the left arm was not manifest within one year of separation from service. 4. The Veteran's right arm disability is not attributable to service and arthritis of the right arm was not manifest within one year of separation from service. 5. The Veteran's respiratory disability is not attributable to service. 6. The Veteran's gallbladder disability is not attributable to service and calculi of the gallbladder was not manifest within one year of separation from service. 7. The Veteran's thyroid disability is not attributable to service. 8. The Veteran's left hand disability is not attributable to service and arthritis of the left hand was not manifest within one year of separation from service. 9. The Veteran's right hand disability is not attributable to service and arthritis of the right hand was not manifest within one year of separation from service. 10. The Veteran's left hip disability is not attributable to service and arthritis of the left hip was not manifest within one year of separation from service. 11. The Veteran's right hip disability is not attributable to service and arthritis of the right hip was not manifest within one year of separation from service. 12. In a July 2014 rating decision, the VA Regional Office denied claims for service connection for diabetes mellitus and Hepatitis C. There was no new and material evidence pertinent to the claims received within one year of the issuance of the decision. The Veteran was notified of the decision and apprised of her appellate rights but did not appeal. 13. The evidence pertaining to diabetes mellitus and Hepatitis C received after the last final rating decision of July 2014 was not previously submitted, relates to an unestablished fact necessary to substantiate the claims, is neither cumulative nor redundant, and raises a reasonable possibility of substantiating the claims. CONCLUSIONS OF LAW 1. Prior to June 10, 2019, the criteria for a disability rating in excess of 50 percent for pervasive depressive disorder were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.130, Diagnostic Code (DC) 9433. 2. Since June 10, 2019, the criteria for a disability rating in excess of 70 percent, but no higher, for pervasive depressive disorder have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.130, DC 9433. 3. The criteria for service connection for a left arm disability have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 4. The criteria for service connection for a right arm disability have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 5. The criteria for service connection for a respiratory disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 6. The criteria for service connection for a disability of the gallbladder have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 7. The criteria for service connection for a thyroid disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 8. The criteria for service connection for a left hand disability have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 9. The criteria for service connection for a right hand disability have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 10. The criteria for service connection for a left hip disability have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 11. The criteria for service connection for a right hip disability have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 12. The July 2014 rating decision denying service connection for diabetes mellitus and Hepatitis C is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.160, 20.1103. 13. Evidence received since the July 2013 rating decision is new and material, and the claims for service connection for diabetes mellitus and Hepatitis C are reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1979 to April 1980 in the United States Army with additional periods of active duty for training and inactive duty for training. These matters come before the Board of Veterans' Appeals (Board) on appeal from June 2017 and November 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office. In August 2019, the Board denied the claim for a higher rating for pervasive depressive disorder, and remanded the remaining claims for further development. While the Board additionally remanded a claim for service connection for a disability manifested by a loss of balance, in a subsequent January 2021 rating decision, the VA Regional Office granted this claim. As such, it is no longer in appellate status and will not be addressed below. Similarly, while the Board remanded a claim involving an earlier effective date for pervasive depressive disorder pursuant to Manlincon v. West, 12 Vet. App. 238 (1999), as an appeal of the claim was not perfected upon the issuance of a statement of the case, the claim is also not in appellate status and will not be addressed here. In June 2021, the Board vacated its August 2019 denial of the claim for a higher rating for pervasive depressive disorder due to the fact that the Veteran had filed extension requests that had not been addressed prior to the issuance of the August 2019 decision. The matter was placed in abeyance for over 90 days to allow the Veteran time to submit any desired evidence. That time has now expired, and the claim has returned for appellate adjudication. The electronic filing system contains VA treatment records that were associated with the file by VA, rather than the Veteran, since the RO's last readjudication of the claim for a higher rating for pervasive depressive disorder without a waiver of RO jurisdiction. However, as the records are duplicative of those previously received or are otherwise not pertinent to the psychiatric claim, there is no risk of prejudice to the Veteran from proceeding without the waiver. Higher Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disability specified is considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. Once a Veteran has been diagnosed with service-connected psychiatric disability, VA reviews his/her medical history to determine how significantly the disorder has disrupted social and occupational functioning. The level of disability is rated according to a General Rating Formula for Mental Disorders, codified at 38 C.F.R. § 4.130 ("General Rating Formula"), which provides for ratings of zero, 10, 30, 50, 70, or 100 percent. Pursuant to 38 C.F.R. § 4.130, DC 9411, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The ratings in the General Rating Formula are associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms; a Veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In the June 2017 rating decision on appeal, service connection for pervasive depressive disorder was granted, and a 50 percent rating was assigned, effective December 8, 2016. As noted above, the claim was denied by the Board in an August 2019 decision. In June 2021, the Board vacated its August 2019 denial, and the matter was held in abeyance for the submission of any additional evidence. The matter has now returned to the Board and will be adjudicated on a de novo basis. Turning to the evidence, in October 2016 VA treatment records, the Veteran was fully oriented and dressed appropriately. Her mood and affect were dysthymic. There were no abnormalities in speech, hallucinations, or delusions. Her memory was adequate. She had some difficulty organizing thoughts and maintaining concentration. There was no homicidal or suicidal ideation. In a December 2016 VA treatment record, it was noted that the Veteran has posttraumatic stress disorder from childhood experiences. She was fully oriented and dressed appropriately for the season. Her mood and affect were dysthymic. There were no abnormalities in speech, hallucinations, or delusions. Her memory was adequate. She had some difficulty organizing thoughts and maintaining concentration. There was no homicidal or suicidal ideation. In January 2017 and February 2017 VA treatment records, the Veteran was fully oriented and there were no hallucinations or delusions. Her memory and judgement were adequate. Insight was influenced by dependency, avoidance, and obsessive compulsiveness. She had some difficulty organizing her thoughts and had trouble concentrating. There was no homicidal or suicidal ideation. On VA examination in April 2017, the Veteran reported that her husband had died, and that her adult son lived with her. She had three other grown children and nine grandchildren who kept her busy. She was caring for her mother, who had cancer. She reported working in part-time jobs, but that she could not work full-time due to her mother's condition. Her symptoms consisted of a depressed mood, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. She was appropriately dressed and had good hygiene. Her mood was somewhat depressed and her affect was slightly blunted but appropriate. Speech was normal, and there were no abnormalities in thought processes. There were no hallucinations, delusions, homicidal ideation, or suicidal ideation. The Veteran was fully oriented, memory was intact, and judgment was intact. The examiner opined that the disability caused occupational and social impairment due to mild or transient symptoms which decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress, or the symptoms were controlled by medication, the "severity statement" associated with a 10 percent rating. In a March 2018 VA treatment record, the Veteran reported having no change in her mood or affect. There was no homicidal ideation, suicidal ideation, or hallucinations. She was able to perform activities of daily living. In a June 2019 Disability Benefits Questionnaire (DBQ) and in an attached narrative report, it was noted that the Veteran had been married once and her husband had died. She had four adult children and lived by herself with help from her sister. Her symptoms consisted of the following: a depressed mood; anxiety; suspiciousness; panic attacks occurring weekly or less often; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; mild memory loss; impairment of short and long term memory; a flattened affect; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships; persistent delusions or hallucinations; neglect of personal appearance and hygiene; and an intermittent inability to perform activities of daily living. Dr B. opined that the disability caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, the "severity statement" associated with a 70 percent rating. She further opined that the Veteran cannot sustain the stress of a competitive work environment or be expected to engage in gainful activity due to her psychiatric disability. Her disability prevents her from getting enough sleep, causes difficulty with memory, and causes problems with sustaining a steady mood. Social interactions at work would be difficult, and her emotional turmoil, absenteeism, and distractibility would be deemed inappropriate in a workplace setting. In a February 2021 statement, the Veteran's sister stated that the Veteran was living with her due to her physical health problems and depression. The Veteran enjoyed going to church and visiting their mother, but avoided large crowds. She had a couple of friends, but was frustrated easily by them. She described that the Veteran has a lack of motivation, gets easily overwhelmed and upset, and is not responsible. She additionally described that the Veteran is moody, paranoid, and isolates herself socially. 1. Prior to June 10, 2019, an initial disability rating in excess of 50 percent for pervasive depressive disorder is denied. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence is against a rating higher than the 50 percent rating currently assigned for the Veteran's pervasive depressive disorder for the period of the appeal dated prior to June 10, 2019. During this portion of the appeal period, the preponderance of the evidence shows few to none of the symptoms contemplated by a 70 percent rating, including suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; or an inability to establish and maintain effective relationships. Rather, the record indicates that during this portion of the appeal period, the Veteran's pervasive depressive disorder was predominantly manifested by a depressed mood, difficulty organizing thoughts, problems with concentration, sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. All of these symptoms correspond to those contemplated by the currently-assigned 50 percent rating, or lower ratings. Additionally, deficiencies in most areas, such as work, school, family relations, judgment, or thinking are not shown by the record. Deficiencies in school were not shown. There were few to no deficiencies in family as the Veteran maintained a close relationship with her sister, children, and grandchildren. There were no deficiencies in judgment or thinking, as both were intact when assessed on multiple occasions throughout the pertinent course of the appeal. Finally, in assessing the severity of the Veteran's pervasive depressive disorder, the April 2017 VA examiner opined that it caused occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication, the symptoms contemplated by a 10 percent rating. This is consistent with the symptoms documented on examination, as well as those documented in the surrounding treatment records. In sum, the Board finds that the overall symptomatology attributable to the Veteran's pervasive depressive disorder most closely approximated the level of severity contemplated by a 50 percent rating for the portion of the appeal period dated prior to June 10, 2019, and the preponderance of the evidence is against any higher rating. In reaching this decision, the Board considered the doctrine of reasonable doubt. 2. Since June 10, 2019, a disability rating of 70 percent, but no higher, for pervasive depressive disorder is granted. For the portion of the appeal period dated since June 10, 2019, the Board finds that the Veteran's symptoms have approximated the criteria for a 70 percent rating. In her June 10, 2019 report, Dr. B. selected the "severity statement" corresponding to a 70 percent rating. She opined that the Veteran's pervasive depressive disorder is manifested by such symptoms as near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; difficulty in adapting to stressful circumstances; and an inability to establish and maintain effective relationships, all of which are contemplated by a 70 percent rating. Further, both the narrative report of Dr. B. and the DBQ indicate that the Veteran manifested occupational and social impairment, with deficiencies in most areas, such as work, thinking, and mood during this time period. There is no evidence to the contrary of the report of Dr. B. While the Veteran has not demonstrated every symptom associated with the 70 percent rating criteria since June 10, 2019, the symptoms noted in the rating schedule are not intended to constitute an exhaustive list. The Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). The Board thus finds that the Veteran's disability picture most closely approximated that contemplated by a 70 percent rating since June 10, 2019. However, the preponderance of the evidence is against the assignment of a 100 percent rating for the Veteran's pervasive depressive disorder since June 10, 2019. Significantly, Dr. B. did not find the disability is manifested by both total occupational and social impairment. Indeed, total social impairment is not shown as the Veteran has maintained a close relationship with her sister and mother. Her sister reported that enjoys attending church and has a couple of friends. Further, nearly none of the symptoms typically associated with a 100 percent rating are shown by the record. The record does not indicate that during the pertinent time frame the Veteran's pervasive depressive disorder has been manifested by a gross impairment in thought processes or communication; grossly inappropriate behavior; a persistent danger of the Veteran hurting herself or others; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. To the extent that Dr. B. indicated that the Veteran experiences persistent delusions or hallucinations and has an intermittent inability to perform activities of daily living, this alone is insufficient to support the assignment of a 100 percent rating, particularly when viewed in light of the Veteran's overall disability picture. In sum, the overall symptomatology attributable to the Veteran's service-connected pervasive depressive disorder has most closely approximated the level of severity contemplated by a 70 percent rating since June 10, 2019, but the preponderance of the evidence is against a rating in excess of 70 percent at any point since that date. In reaching this decision the Board considered the doctrine of reasonable doubt. Service Connection VA provides compensation for disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a "service connection." 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to show a service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in or aggravated in the line of duty, or any period of inactive duty for training (INACDUTRA) during which the individual concerned was disabled from an injury, but not also disease, incurred in or aggravated in the line of duty, or when a cardiac arrest or cerebrovascular accident occurs during such training. 38 U.S.C. §§ 101(21), (24), 106; 38 C.F.R. § 3.6(a), (d). Additionally, for certain chronic diseases, including arthritis and calculi of the gallbladder, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For those listed chronic diseases, a showing of continuity of symptoms affords an alternative route to service connection when the requirements for application of the presumption are not met. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). 3. Service connection for a left arm disability is denied. 4. Service connection for a right arm disability is denied. 5. Service connection for a respiratory disability is denied. 6. Service for a gallbladder disability is denied. 7. Service connection for a thyroid disability is denied. 8. Service connection for a left hand disability is denied. 9. Service connection for a right hand disability is denied. The Veteran has current chronic obstructive pulmonary disease, gallbladder adenomyomatosis, and primary hyperparathyroidism documented, for example, in March 2018 and August 2018 VA treatment records. Additionally, the Board resolves any doubt in favor of the Veteran as to the presence of a bilateral hand and arm disability to the extent she experiences pain with functional impairment in the hands and arms. See Martinez-Bodon, 32 Vet. App. at 393; Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), (holding that pain alone, when causing functional impairment, may constitute a "disability" for VA compensation purposes, even if the pain is not accompanied by a medical diagnosis.) Her contentions regarding the relationship of these disabilities to military service are unknown from the pleadings. A review of the service treatment records reveals no documentation of any diagnoses, complaints, or treatment related to a respiratory disability, gallbladder disability, thyroid disability, or left hand disability. While the Veteran reported muscle spasms in the arms in January and February 1991, the assessment was muscle pain due to a lack of conditioning. Similarly, in August 1987 she sought treatment for a swollen right hand and was assessed with sore muscles due to exercise. Service treatment records dated subsequent to the 1987 and 1991 records are silent for any further complaints or treatment pertaining to the arms or right hand. The Board infers from this that the 1987 and 1991 muscle pain did not result in chronic disability in service and thus, was acute and transitory. On her March 1980 separation examination, no pertinent abnormalities were found, and the Veteran raised no relevant complaints. A review of the post-service medical records does not reveal documentation of arthritis of the arms or hands or calculi of the gallbladder within one year of her April 1980 discharge. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence is against the claims. The probative evidence does not show that the Veteran's disabilities are related to her active military service, or that a chronic disability was incurred in service. The service treatment records are silent for pertinent documentation, other than the acute and transitory episodes discussed above, and no abnormalities were found on her March 1980 separation examination. A pertinent disability was not found within one year of separation from service, nor is there x-ray evidence of arthritis of the arms or hands or documentation regarding calculi of the gallbladder from this time. Rather, the evidence reflects that the current disabilities were not shown until many years after service discharge. The fact that she sought treatment for other conditions after service, but not a respiratory disability, gallbladder disability, thyroid disability, bilateral hand disability, or bilateral arm disability, weighs against the credibility of any assertion that the current disabilities persisted since discharge. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). The claims file contains VA treatment records dating back to 2001 documenting a variety of complaints, without mention of respiratory disability, gallbladder disability, thyroid disability, bilateral hand disability, or bilateral arm disability in the earliest records. Because she described other complaints of musculoskeletal pain and provided overall assessments of her health and functioning to her general practitioners, without mention of these conditions, it is reasonable to conclude that none were present. Id.; see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The record does not include an opinion on the matter of service connection. VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). Here, the Board finds that there is no indication, other than the Veteran's general assertions of service connection, of an association between a respiratory disability, gallbladder disability, thyroid disability, bilateral hand disability, or bilateral arm disability and service. However, she does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of such medically complex disabilities. See, e.g., Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). Her statements alone are thus insufficient to warrant a medical examination as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. See, e.g., Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). She has been examined on several occasions by VA and private providers for various medical problems, and none indicated or suggested any relationship between these disabilities and service. Consequently, VA is under no duty to obtain a medical opinion addressing direct service connection as to these disabilities. In reaching this decision the Board considered the doctrine of reasonable doubt, however, the doctrine is not for application. 10. Service connection for a left hip disability is denied. 11. Service connection for a right hip disability is denied. The Veteran has a current right hip strain, documented on VA examination in May 2017, and left hip arthritis, documented in a June 2008 VA treatment record. Her contentions regarding the relationship of these disabilities to military service are unknown from the pleadings. Rather, on VA examination in May 2017, she reported that her hip pain did not begin until 2012-2013. A review of the service treatment records reveals no documentation of any diagnoses, complaints, or treatment related to a hip disability. While she reported various problems pertaining to her back and lower extremities during military service, the records are silent for any documentation specific to the hips. On her March 1980 separation examination, no pertinent abnormalities were found, and the Veteran raised no complaints regarding her hips. A review of the post-service medical records does not reveal documentation of arthritis of the hips within one year of the Veteran's April 1980 discharge. On the matter of the etiology of the disabilities, the record contains VA examination reports of May 2014 and May 2017. On VA examination in May 2014, the examiner reviewed the record and examined the Veteran. The examiner opined that the current bilateral hip symptomatology was less likely than not proximately due to or a result of military service. While the Veteran's March 1980 discharge examination documented complaints of leg cramps, an examination of her hips was normal. The examiner indicated that beginning in 2012, the Veteran's health began to deteriorate and she was hospitalized on multiple occasions. The examiner opined that her bilateral hip symptoms are most likely related to very poor physical conditioning. On VA examination in May 2017, the examiner reviewed the claims file and examined the Veteran. She opined that the current right hip disability was less likely than not incurred in or caused by service. The examiner noted that service treatment records did not document any reports of hip pain, and that the earliest documentation of bilateral hip pain of record is dated from 2001. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence is against the claims. The probative evidence does not show that the Veteran's hip disabilities are related to her active military service, or that a chronic disability was incurred in service. The service treatment records are silent for pertinent documentation, and no abnormalities were found on her March 1980 separation examination. A pertinent disability was not found within one year of separation from service, nor is there x-ray evidence of arthritis of either hip from this time; rather, the evidence reflects that the current disabilities were not shown until many years after service discharge. The fact that she sought treatment for other conditions in service, but not a right or left hip disability, weighs against the credibility of any assertion that these disabilities were present in service. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). The medical opinion evidence is also persuasive. The VA examiners addressed the contentions of direct service connection, but opined that the current bilateral hip disability is not related to military service. The May 2014 VA examiner identified another etiology of the current disability, namely, poor physical conditioning. The examiners based their conclusions on an examination of the claims file, including the post-service treatment records and diagnostic reports. They reviewed and accepted the reported history and symptoms in rendering the opinions, and provided a rationale for the conclusions reached. The only evidence to the contrary of the VA examiners' opinions is the lay evidence. The Veteran, however, does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of such a medically complex disability as a hip strain or arthritis. See, e.g., Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). In reaching this decision the Board considered the doctrine of reasonable doubt, however, the doctrine is not for application. Applications to Reopen Generally, a claim that has been denied in a final, unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105. An exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence, 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, and it must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held, however, that evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343 (2000). In deciding whether new and material evidence has been received, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). 12. As new and material evidence sufficient to reopen the previously denied claim for service connection for diabetes mellitus has been received, the application to reopen is granted. 13. As new and material evidence sufficient to reopen the previously denied claim for service connection for Hepatitis C has been received, the application to reopen is granted. In a rating decision of July 2014, the VA Regional Office denied service connection for diabetes mellitus and Hepatitis C. The evidence consisted of statements from the Veteran, her service treatment records, and VA treatment records. The VA Regional Office denied the claims due to a lack of evidence showing that the disabilities were incurred in or caused by service, or that diabetes mellitus became manifest within one year of discharge. There was no material evidence received within one year of the issuance of the July 2014 rating decision. The Veteran was notified of the decision and of her appellate rights but did not appeal. The July 2014 decision is therefore final as to the evidence then of record, and is not subject to revision on the same factual basis. In February 2021, the Veteran submitted an October 2019 report of Dr. B. In the report, Dr. B. indicated that the Veteran's service-connected psychiatric disability has caused her to abuse alcohol, and such alcohol abuse has more likely than not resulted in a variety of disabilities, including Hepatitis C. Dr. B. additionally opined that the Veteran's pancreatitis, cirrhosis, and hypertension, caused by alcohol abuse, more likely than not caused the Veteran's diabetes. The Board finds that the October 2019 report of Dr. B. is "new" evidence in that it was not before the VA Regional Office in July 2014, and is not duplicative or cumulative of evidence previously of record. This evidence is also "material" as it lends support to an element of the Veteran's claims for service connection, that of a relationship between the current diabetes mellitus and Hepatitis C, and her service-connected psychiatric disability. When viewed in the context of the reason for the prior denial, the added evidence cures a prior evidentiary defect. Accordingly, the criteria for reopening the claim are met. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156. REASONS FOR REMAND 1. Service connection for hypertension is remanded. 2. Service connection for pancreatitis is remanded. 3. Service connection for a neurological disability of the left upper extremity is remanded. 4. Service connection for a neurological disability of the right upper extremity is remanded. 5. Service connection for a neurological disability of the left lower extremity is remanded. 6. Service connection for a neurological disability of the right lower extremity is remanded. 7. Service connection for diabetes mellitus is remanded. 8. Service connection for Hepatitis C is remanded. The Veteran has current hypertension, pancreatitis, neuropathy of the upper and lower extremities, diabetes mellitus, and Hepatitis C, documented, for example, in the October 2019 report of Dr. B. In her October 2019 report, Dr. B. stated that the Veteran developed an alcohol abuse disorder due to her service-connected psychiatric disability. Dr. B. then attributed the Veteran's neuropathy, Hepatitis C, hypertension, and pancreatitis to alcohol abuse, diabetes to pancreatitis and hypertension, and neuropathy also to diabetes. In support, in February 2021, the Veteran additionally submitted medical literature addressing the relationships among these various disabilities. Generally, VA compensation may not be paid for primary substance abuse disabilities, or for secondary disabilities arising from primary abuse. See 38 U.S.C. §§ 105, 1110; 38 C.F.R. §§ 3.1, 3.301. However, compensation may be paid for substance abuse that is secondary to, or a symptom of, a service-connected disability. See 38 C.F.R. § 3.310; see also Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). Compensation may be awarded only "where there is clear medical evidence establishing that alcohol or drug abuse is caused by a veteran's primary service-connected disability, and where the alcohol or drug abuse disability is not due to willful wrongdoing." Allen, 237 F. 3d at 1381. The Veteran is not currently service-connected for an alcohol-abuse disorder, and the Board finds the statement provided by Dr. B. linking the Veteran's alcohol abuse disorder to her service-connected pervasive depressive disorder is not supported by a full rationale. Moreover, in contrast to the finding of Dr. B., a December 2012 VA treatment record indicates that the Veteran has had an alcohol abuse disorder since the age of 18, predating military service and the onset of her service-connected psychiatric disability. A VA examination addressing the etiology of these claims has not been afforded, and one must be obtained prior to appellate adjudication. The opinion of Dr. B. provides an indication that the current disabilities may be related to the Veteran's service-connected psychiatric disabilities via an alcohol abuse disorder as an "intermediate" step. The report of Dr. B. and the medical literature submitted by the Veteran must be addressed by the VA examiner. 9. Service connection for a disability of the eyes is remanded. The record indicates that the Veteran has disabilities of the eyes that may be related to her hypertension and/or diabetes mellitus. For example, in an April 2015 VA treatment record, she was diagnosed with diabetic retinopathy affecting the left eye, and in a November 2017 VA treatment record, she was diagnosed with ocular hypertension. As a decision on the claims for hypertension and diabetes mellitus could significantly impact a decision on claim for service connection for a disablity of the eyes, the issues are inextricably intertwined. A remand of the claim for a disability of the eyes is thus required. 10. A TDIU is remanded. The claim for a TDIU has been added to the appeal pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran does not currently meet the schedular requirements for an award of a TDIU pursuant to 38 C.F.R. § 4.16(a) for the entirety of the appeal period. Should any of the above-remanded claims result in an award of service connection, the ratings assigned, effective dates awarded, and any statements made on VA examination as to the Veteran's employability will impact adjudication of the claim for a TDIU. As such, the issues are inextricably intertwined and a remand of the claim for a TDIU is thus also required. The matters are REMANDED for the following action: 1. Provide the Veteran's electronic claims file to a VA psychologist or psychiatrist to obtain an opinion regarding the nature of the Veteran's alcohol abuse disorder. Unless determined otherwise by the VA examiner, an actual examination of the Veteran is not required. Based on a review of all pertinent lay and medical evidence, the examiner must opine as to whether it is at least as likely as not that the Veteran's alcohol abuse is a primary disorder or a secondary disorder caused or aggravated by her service-connected pervasive depressive disorder. The examiner must explain the rationale for all opinions rendered, citing to supporting factual data and/or medical literature, as appropriate. In this rendering these opinions, the examiner is asked to consider the following: October 2019 opinion of Dr. B. linking the Veteran's alcohol abuse disorder to her service-connected pervasive depressive disorder December 2012 VA treatment record indicating that the Veteran has had an alcohol abuse disorder since the age of 18, predating military service and the onset of her service-connected psychiatric disability. Medical literature submitted by the Veteran in February 2021 addressing substance abuse disorders and psychological disabilities 2. IF, and only if, the psychiatric opinion obtained in response to the above remand directive indicates that the Veteran has an alcohol abuse disorder secondary to her service-connected pervasive depressive disorder, schedule the Veteran for a VA examination(s) to obtain an opinion addressing the nature and etiology of EACH of the following disabilities: (a.) hypertension (b.) pancreatitis (c.) neurological disability of the arms (d.) neurological disability of the legs (e.) diabetes mellitus (f.) Hepatitis C A rationale must be provided for all conclusions reached. While a medical opinion is required, the examiner is asked to consider the Veteran's lay reports and may state whether they are medically-consistent or medically-inconsistent with other evidence of record. The examiner must respond to the following inquiries: (A.) Is it at least as likely as not that ANY of the above disabilities began during any period of active service or are related to an in-service injury, event, or disease? If yes, why? (B.) Is it at least as likely as not that ANY of the above claimed disabilities have been (i.) caused or (ii.) aggravated (i.e., worsened) by the Veteran's alcohol abuse disorder? If yes, why? In this rendering this opinion, the examiner is asked to consider the following: October 2019 opinion of Dr. B. linking the above-claimed disabilities to the Veteran's alcohol abuse disorder or to one another Medical literature submitted by the Veteran in February 2021 pertaining to alcohol use and the above-claimed disabilities M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Smith, 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.