Citation Nr: 21071001 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 16-14 565 DATE: November 29, 2021 ORDER New and material evidence has been received and the petition to reopen a claim of service connection for depression is granted. New and material evidence has been received and the petition to reopen a claim of service connection for a left foot disability, to include compensation under 38 U.S.C. § 1151, is granted. New and material evidence has been received and the petition to reopen a claim of service connection for a bilateral hand disability is granted. REMANDED Entitlement to service connection for depression is remanded. Entitlement to service connection for a left foot disability, to include compensation under 38 U.S.C. § 1151, is remanded. Entitlement to service connection for a bilateral hand disability is remanded. Entitlement to service connection for a left wrist disability is remanded. Entitlement to service connection for a bilateral hip disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for stroke is remanded. The issue of whether new and material evidence has been received to reopen a claim of service connection for diabetes mellitus, type II (DMII) is remanded. The issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for bilateral upper extremity peripheral neuropathy secondary to DMII is remanded. The issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for a cardiovascular disorder is remanded. The issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for hypertension is remanded. The issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for the Veteran's cause of death is remanded. Entitlement to survivor's pension benefits is remanded. FINDINGS OF FACT 1. In a July 2005 rating decision, VA denied service connection for depression on the basis that the Veteran's depression was not incurred in or otherwise caused by active service and it was not secondary to service-connected disabilities. The Veteran filed a timely notice of disagreement in December 2005 and VA issued a statement of the case (SOC) in May 2007. The Veteran did not file a substantive appeal; therefore, the July 2005 rating decision became final. 2. In an August 2008 rating decision, VA declined to reopen the claim of service connection for depression on the basis that new and material evidence had not been received. The Veteran filed a timely notice of disagreement in October 2008 and VA issued a SOC in May 2010. The Veteran did not file a timely substantive appeal; therefore, the August 2008 rating decision became final. Evidence received since the August 2008 rating decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the underlying claim. 3. In a June 2002 rating decision, VA denied entitlement to compensation under 38 U.S.C. § 1151 on the basis that the Veteran had not identified the VA medical center that she was treated at that created the additional disability. The Veteran did not file a notice of disagreement; therefore, the June 2002 rating decision became final. Evidence received since the June 2002 rating decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the underlying claim. 4. In a June 2007 rating decision, VA denied service connection for a bilateral hand disability on the basis that the Veteran's service medical records did not show complaints of or treatment for such a condition during service nor had the Veteran provided evidence of a current disability. The Veteran did not file a notice of disagreement; therefore, the June 2007 rating decision became final. Evidence received since the June 2007 rating decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the underlying claim. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen a claim of service connection for depression. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. § 3.156 (2020). 2. New and material evidence has been received to reopen a claim of service connection for a left foot disability, to include compensation under 38 U.S.C. § 1151. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. § 3.156 (2020). 3. New and material evidence has been received to reopen a claim of service connection for a bilateral hand disability. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. § 3.156 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1974 to July 1974, with additional service in the Army National Guard and Army Reserve. The Veteran died in August 2014. The Appellant is her surviving spouse. These matters come to the Board of Veterans' Appeals (Board) on appeal from June 2012, August 2012, and December 2013 rating decisions. The Appellant has been granted substitution for these claims. These matters also come to the Board from a February 2017 decision which denied entitlement to Dependency and Indemnity Compensation, accrued benefits, and survivor's pension benefits. In October 2018 and September 2020, the Board remanded the matters for further development, to include verifying the Veteran's periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). Reopening Claims Despite the RO's action, the Board must perform its own de novo review of whether new and material evidence has been received to reopen the claims of entitlement to service connection for depression, a left foot disability, and a bilateral hand disability before addressing the claims on their merits. See 38 U.S.C. § 7104; see also Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. Rating actions from which an appeal is not timely perfected become final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A Board decision becomes final when it is issued as of the date-stamped on the decision unless the appellant continues the appeal to the court or a motion for reconsideration is granted by the Board. 38 U.S.C. § 7104; 38 C.F.R. § 20.1100. A final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C. § 5108. In general, if new and material evidence is presented or secured with respect to a finally adjudicated claim, VA shall reopen and review the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decision makers. 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 sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether new and material evidence has been submitted, the Board must consider the specific reasons for the prior denial. Evans v. Brown, 9 Vet. App. 273, 283 (1996); Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The provisions of 38 C.F.R. § 3.156(a) create a low threshold, with the phrase "raises a reasonable possibility of substantiating the claim" enabling rather than precluding reopening and not constituting a third requirement that must be met before the claim is reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). 1. Whether new and material evidence has been received to reopen a claim of service connection for depression. In a July 2005 rating decision, VA denied service connection for depression on the basis that the Veteran's depression was not incurred in or otherwise caused by active service and it was not secondary to service-connected disabilities. The Veteran filed a timely notice of disagreement in December 2005 and VA issued a statement of the case (SOC) in May 2007. VA explained that while the Veteran had depressive symptoms, the evidence did now show that such was caused by her service-connected right knee and right foot conditions but rather, was attributable to her other physical ailments. The Veteran did not file a substantive appeal; therefore, the July 2005 rating decision became final. In January 2008, the Veteran attempted to reopen her claim of service connection for depression. An August 2008 rating decision declined to reopen the claim of service connection for depression on the basis that new and material evidence had not been received. The Veteran filed a timely notice of disagreement in October 2008 and VA issued a SOC in May 2010. VA explained that while additional reserve service medical records were received, as well as a statement from her treating clinician, the records did not show evidence of depression related to service or secondary to a service-connected disability. Thus, VA found that new and material evidence had not been received. The Veteran filed a substantive appeal in October 2010, and in a November 2010 letter, VA informed the Veteran that her substantive appeal was untimely. She did not appeal this decision; therefore, the August 2008 rating decision became final. In April 2013, the Veteran attempted to reopen her claim of service connection for depression. Evidence received since the last final August 2008 rating decision includes VA treatment records, private treatment records, an appellant statement, leave and earning statements dated from July 1978 through December 2007, and appellate briefs. In a July 2020 statement, the Appellant remembered the Veteran's chronic pain, how it limited her mobility, and how it affected her mentally. Here, the Board finds that new and material evidence within the meaning of 38 C.F.R. § 3.156(a) has been received since the last, final August 2008 rating decision. Specifically, a statement from the Veteran's spouse shows that the Veteran's depression may have been caused or aggravated by pain and limited mobility due to her service-connected disabilities. The Appellant's statement is presumed credible for purposes of determining whether new and material evidence has been received to reopen a previously final decision. Thus, new evidence submitted since the RO's August 2008 rating decision, when considered with the previous evidence of record, relates to unestablished facts (i.e., a nexus) necessary to substantiate the claim. Therefore, new and material evidence has been received since the RO's August 2008 rating decision and reopening the claim of service connection for depression is warranted. The Veteran's petition is granted only to this extent. 2. Whether new and material evidence has been received to reopen a claim of service connection for a left foot disability, to include compensation under 38 U.S.C. § 1151. In a June 2002 rating decision, VA denied entitlement to compensation under 38 U.S.C. § 1151 on the basis that the Veteran had not identified the VA medical center that she was treated at that created the additional disability. VA notified the Veteran of the decision by letter in June 2002, but the Veteran did not file a notice of disagreement; therefore, the June 2002 rating decision became final. In a July 2009 VA Form 21-4138 (Statement in Support of Claim), the Veteran attempted to reopen her claim for a left foot postoperative condition. Initially, the Board notes that in a March 2012 letter, VA informed the Veteran that she had previously been denied service connection for a left foot disorder and that she would need to submit new and material evidence to reopen her claim. While a new theory of entitlement cannot be the basis to reopen a claim under 38 U.S.C. § 7104(b), if the evidence supporting a new theory of entitlement constitutes new and material evidence, then VA must reopen the claim. Boggs v. Peake, 520 F.3d 1330, 1336-37 (Fed. Cir. 2008). In a June 2012 rating decision, VA adjudicated service connection for a left foot disability on the merits, finding that there was no evidence of a left foot condition during service. As such, the Board finds that there was an implicit finding of new and material evidence by VA. Despite this, the Board must perform its own de novo review of whether new and material evidence has been received. Evidence received since the last final June 2002 rating decision includes VA treatment records, private treatment records, statements from the Veteran's treating clinician, an appellant statement, and leave and earning statements dated from July 1978 through December 2007. Private treatment records dated in August 2002 reflect the Veteran reported surgery on her foot in 1996 and that she had recently experienced increased pain. VA treatment records dated in October 2003 reflect that she reported that her left foot had been swollen since after foot surgery. A February 2007 VA examination report reflects that the Veteran reported surgery on her foot in 1996 or 1997 and that she had had residuals of pain and swelling since. VA treatment records from the West Los Angeles VA Medical Center (VAMC) obtained in June 2012 and dating back to May 1996 reflect that the Veteran underwent a prior surgery in October 1997 and that she had the hardware surgically removed at the West LA VAMC in July 1998. Here, the Board finds that new and material evidence within the meaning of 38 C.F.R. § 3.156(a) has been received since the last, final June 2002 rating decision. Specifically, VA treatment records show that the Veteran underwent surgery at the West LA VAMC and that she continued to report pain and swelling subsequent to her surgery. Thus, new evidence submitted since the RO's June 2002 decision, when considered with the previous evidence of record, relates to unestablished facts (i.e., treatment at a VA medical center) necessary to substantiate the claim. Therefore, new and material evidence has been received since the RO's June 2002 rating decision and reopening the claim of service connection for a left foot disability, to include compensation under 38 U.S.C. § 1151, is warranted. The Veteran's petition is granted only to this extent. 3. Whether new and material evidence has been received to reopen a claim of service connection for a bilateral hand disability. In a June 2007 rating decision, VA denied service connection for a bilateral hand disability on the basis that the Veteran's service medical records did not show complaints of or treatment for such a condition during service nor had the Veteran provided evidence of a current disability. VA notified the Veteran of the decision by letter in June 2007, but she did not file a notice of disagreement. The Board notes that it appears the Veteran's service medical records pertaining to her reserve service were associated with the record prior to the June 2007 rating decision. Specifically, a May 2007 SOC listed the Veteran's reserve medical records as evidence. The June 2007 rating decision did not list her reserve service medical records as evidence or appear to discuss those records. However, as these records were associated with the record prior to the decision, the exception to the requirement of new and material evidence under 38 C.F.R. § 3.156(c) is not applicable in this instance. The Veteran did not file a notice of disagreement with the June 2007 rating decision; therefore, the June 2007 rating decision became final and new and material evidence is required to reopen her claim. In July 2009, the Veteran attempted to reopen her claim of service connection for a bilateral hand disability. Evidence received since the last final June 2007 rating decision includes VA treatment records, private treatment records, and leave and earning statements dated from July 1978 through December 2007. VA treatment records dated in January 2010 reflect a history of surgery to her hands. In January 2012 and July 2013, she complained of pain in her hands. The Board notes that pain can constitute a disability if it results in impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). Here, the Board finds that new and material evidence within the meaning of 38 C.F.R. § 3.156(a) has been received since the last, final June 2007 rating decision. Specifically, the evidence shows complaints of bilateral hand pain which can constitute a disability for VA purposes. Thus, new evidence submitted since the RO's June 2007 decision, when considered with the previous evidence of record, relates to unestablished facts (i.e., a current disability) necessary to substantiate the claim. Therefore, new and material evidence has been received since the RO's June 2007 rating decision and reopening the claim of service connection for a bilateral hand disability is warranted. The Veteran's petition is granted only to this extent. REASONS FOR REMAND Upon review of the record, there appear to be outstanding private treatment records relevant to the Veteran's claims. Specifically, service medical records and VA treatment records reflect that the Veteran's primary healthcare provider was through Kaiser and that these records may be relevant to the claims on appeal. A remand is required to allow VA to obtain authorization and request these records. A July 1998 letter to VA reflects that the Veteran applied for Social Security disability benefits and VA treatment records reflect that the Veteran was in receipt of Social Security disability benefits prior to her death. Social Security Administration records are not associated with the record and may be relevant to the claims on appeal. A remand is required to allow VA to request these records. 1. Entitlement to service connection for depression is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for depression at this time because no VA examiner has opined whether the Veteran's depression was incurred in or aggravated by a period of ACDUTRA or was secondary to pain from her service-connected disabilities. 2. Entitlement to service connection for a left foot disability, to include compensation under 38 U.S.C. § 1151, is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a left foot disability at this time. The Veteran contends that service connection for a left foot disability is warranted. Alternatively, the Veteran contends that compensation is warranted for a left foot disability under 38 U.S.C. § 1151. No VA examiner has opined whether the Veteran's left foot disability was incurred in or aggravated by service, to include a period of ACDUTRA, or whether the elements of a 38 U.S.C. § 1151 claim have been met. A remand is required to obtain a VA medical opinion. 3. Entitlement to service connection for a bilateral hand disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a bilateral hand disability at this time because no VA examiner has opined whether the Veteran's bilateral hand disability was incurred in or aggravated by service, to include a period of ACDUTRA. 4. Entitlement to service connection for a left wrist disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a left wrist disability at this time because no VA examiner has opined whether the Veteran's left wrist disability was incurred in or aggravated by service, to include a period of ACDUTRA. Furthermore, while the Board remanded this issue most recently in September 2020, the issue was not included on the August 2021 supplemental statement of the case (SSOC) prior to the return of this issue to the Board. As such, remand is required. 5. Entitlement to service connection for a bilateral hip disability is remanded. 6. Entitlement to service connection for a left knee disability is remanded. The Board cannot make a fully-informed decision on the issues of entitlement to service connection for a bilateral hip and left knee disabilities at this time because no VA examiner has opined whether the Veteran's bilateral hip and/or left knee disabilities were incurred in or aggravated by service, to include a period of ACDUTRA, or were secondary to service-connected disabilities. 7. Entitlement to service connection for a right ankle disability is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for a right ankle disability at this time. An August 1977 VA examination report reflects a finding by the examiner that it was impossible to tell at the time how much of the Veteran's right ankle disability was related to her service but that it was possible that she had relaxed ankle ligaments which allowed her to twist her foot somewhat more easily than normal and contributed to her recent 1977 ankle fracture. Speculative language does not create an adequate nexus for the purposes of establishing service connection. See Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative). Additionally, the examiner did not indicate whether there was any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided. As such, the Board finds this opinion inadequate. A July 2012 VA examiner opined that the Veteran's right ankle disability was less likely than not incurred in or caused by service or her service-connected right foot disability, explaining that while the Veteran suffered a swollen foot while in training in 1974, she did not suffer an ankle injury until 1977. Thus, the examiner concluded that there was no evidence that the right ankle disability was the result of the in-service foot injury or service. From this opinion, it is not clear whether the examiner considered a July 2, 1974 service medical record showing complaints of a right ankle sprain or a July 9, 1974 service medical record showing complaints of continued right ankle pain. As such, the Board finds the July 2012 opinion inadequate. Finally, no examiner has opined whether the Veteran's right ankle disability was aggravated by service-connected disability. A remand is warranted for a new VA medical opinion as to the nature and etiology of the Veteran's right ankle disability. 8. Entitlement to service connection for stroke is remanded. Because a decision on the remanded issues of whether new and material evidence has been received to reopen claims of service connection for hypertension and a cardiovascular disorder could significantly impact a decision on the issue of entitlement to service connection for stroke, the issues are inextricably intertwined. A remand of the claim of service connection for stroke is required. 9. The issue of whether new and material evidence has been received to reopen a claim of service connection for diabetes mellitus, type II (DMII) is remanded. 10. The issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for bilateral upper extremity peripheral neuropathy secondary to DMII is remanded. 11. The issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for a cardiovascular disorder is remanded. 12. The issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for hypertension is remanded. The claims of service connection for hypertension and bilateral upper extremity peripheral neuropathy were most recently denied in a July 2005 rating decision. While the Veteran filed a notice of disagreement and VA issued a statement of the case in May 2007, the Veteran did not file a substantive appeal and the decision became final. The claims of service connection for DMII and hypertension were most recently denied in an August 2008 rating decision. While the Veteran filed a notice of disagreement and VA issued a statement of the case in May 2010, the Veteran did not file a timely substantive appeal and the decision became final. Evidence received since the May 2007 and May 2010 statements of the case is not sufficient to reopen the claims. The Board notes that a remand of these petitions to reopen is warranted as there are outstanding medical records which may or may not provide a basis to reopen the claims. Although the Veteran was notified previously of the type of evidence that is needed to reopen the claims, to date, neither the Veteran nor the Appellant has submitted evidence that would provide a basis to reopen the claims. Therefore, the Appellant is advised again to submit new and material evidence if he wants to have these previously denied claims reopened. 13. The issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for the Veteran's cause of death is remanded. The claim of entitlement to service connection for the Veteran's cause of death was previously denied in a February 2015 rating decision. The Appellant did not file a notice of disagreement and the February 2015 rating decision became final. Evidence received since the February 2015 rating decision is not sufficient to reopen the claim. The Board notes that a grant of the pending claims for service connection may or may not provide a basis to reopen the claim. However, to date, the Appellant has not submitted evidence that would provide a basis to reopen the claim. Therefore, the Appellant is advised again to submit new and material evidence if he wants to have this previously denied claim reopened. 14. Entitlement to survivor's pension benefits is remanded. In a February 2015 decision, the Appellant was granted survivor's pension benefits effective September 1, 2014. However, benefits were terminated effective September 1, 2015 due to excessive income. The Appellant reapplied for survivor's pension benefits in February 2017. A February 2017 decision denied survivor's pension benefits on the basis of excessive income and the Appellant filed a timely notice of disagreement. The most recent information submitted by the Appellant on his net worth, income, and unreimbursed medical expenses are dated in 2017. As the Appellant's income may have decreased or his unreimbursed medical expenses increased, the Appellant should be provided with an opportunity to provide updated information on his income and unreimbursed medical expenses. The matters are REMANDED for the following actions: 1. Ask the Appellant to complete a VA Form 21-4142 for treatment the Veteran received from Kaiser beginning in 1991, if not earlier. Make two requests for the authorized records from Kaiser unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's federal records from the Social Security Administration, including records related to her claim for disability benefits in 1998. Document all requests for information as well as all responses in the claims file. 3. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the Veteran's depression. The examiner must review the claims file. The examiner is asked to provide a response to the following: Did the Veteran's depression clearly and unmistakably (undebatable) preexist the Veteran's service, to include any period of ACDUTRA? If the examiner finds the Veteran's depression did clearly and unmistakably preexist a period of service, was it clearly and unmistakably not aggravated by a period of service? If the examiner finds that the Veteran's depression either did not clearly and unmistakably preexist a period of service or was not clearly and unmistakably not aggravated by a period of service, the examiner must opine whether it is at least as likely as not related to service, to include a period of ACDUTRA. If the examiner finds that the Veteran's depression was not incurred in or otherwise related to service, the examiner must opine whether her depression was at least as likely as not (1) proximately due to pain from her service-connected disabilities, or (2) aggravated, i.e., worsened beyond its natural progression, by pain from her service-connected disabilities? Provide a rationale to support the opinion(s). Although a complete review of the claims file is required, the examiner's attention is drawn to an October 1997 VA examination report noting antalgic gait, in part, secondary to right knee pain; an April 2002 right knee evaluation finding that the Veteran should avoid engaging in activities which require prolonged standing, walking, climbing, stooping, kneeling, and crouching; a March 2003 VA treatment record noting the Veteran felt depressed and was not looking forward to her upcoming military duty; and a May 2003 VA treatment record finding that the Veteran's mild to moderate depression was primarily related to her pain and subsequent lack of activity. 4. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the Veteran's left foot disability. The examiner must review the claims file. The examiner is asked to provide a response to the following: Did the Veteran's left foot disability clearly and unmistakably (undebatable) preexist the Veteran's service, to include any period of ACDUTRA? If the examiner finds the Veteran's left foot disability did clearly and unmistakably preexist a period of service, was it clearly and unmistakably not aggravated by a period of service? If the examiner finds that the Veteran's left foot disability either did not clearly and unmistakably preexist a period of service or was not clearly and unmistakably not aggravated by a period of service, the examiner must opine whether it is at least as likely as not related to service, to include a period of ACDUTRA. If the examiner finds that the Veteran's left foot disability was not incurred in or otherwise related to service, did the Veteran sustain any additional disability as a result of VA care, to include a September 1997 Lapidus procedure and internal fixation of the first metatarsal cuneiform joint with subsequent pain and swelling and August 1998 hardware removal? If so, identify any additional disability. If additional disability was sustained as a result of VA care, was it the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing hospital care or medical or surgical treatment? If additional disability was sustained as a result of VA care, was such an event not reasonably foreseeable by a health care provider (VA)? If additional disability was sustained as a result of VA care, did VA fail to exercise the degree of care that would be expected of a reasonable health care provider? If additional disability was sustained as a result of VA care, was this a risk that a reasonable health care provider (a) would have considered to be an ordinary risk of the treatment provided, or (b) would have disclosed in connection with the informed consent procedures? Provide a rationale to support the opinion(s). 5. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the Veteran's bilateral hand and left wrist disabilities. The examiner must review the claims file. The examiner is asked to provide a response to the following: For each of the Veteran's bilateral hand and left wrist disabilities, did the Veteran's disability clearly and unmistakably (undebatable) preexist the Veteran's service, to include any period of ACDUTRA? If the examiner finds the Veteran's bilateral hand and/or left wrist disabilities did clearly and unmistakably preexist a period of service, was it clearly and unmistakably not aggravated by a period of service? If the examiner finds that the Veteran's bilateral hand and/or left wrist disabilities either did not clearly and unmistakably preexist a period of service or were not clearly and unmistakably not aggravated by a period of service, the examiner must opine whether the disability is at least as likely as not related to service, to include a period of ACDUTRA. Provide a rationale to support the opinion(s). 6. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the Veteran's bilateral hip, left knee, and right ankle disabilities. The examiner must review the claims file. The examiner is asked to provide a response to the following: Did the Veteran's bilateral hip, left knee, and/or right ankle disabilities clearly and unmistakably (undebatable) preexist the Veteran's service, to include any period of ACDUTRA? If the examiner finds the Veteran's bilateral hip, left knee, and/or right ankle disabilities did clearly and unmistakably preexist a period of service, was the disability clearly and unmistakably not aggravated by a period of service? If the examiner finds that the Veteran's bilateral hip, left knee, and/or right ankle disabilities either did not clearly and unmistakably preexist a period of service or were not clearly and unmistakably not aggravated by a period of service, the examiner must opine whether the disability is at least as likely as not related to service, to include a period of ACDUTRA. If the examiner finds that the Veteran's bilateral hip, left knee, and/or right ankle disabilities were not incurred in or otherwise related to service, were the disabilities at least as likely as not (1) proximately due to service-connected disabilities, to include altered gait caused by those disabilities, or (2) aggravated, i.e., worsened beyond its natural progression, by her service-connected disabilities, to include an altered gait caused by those disabilities? Provide a rationale to support the opinion(s). 7. Ask the Appellant to provide updated and complete information pertaining to his net worth, income, and unreimbursed medical expenses since February 2017. 8. After completing the above, and any other development as may be indicated, the Veteran's and Appellant's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Appellant and his representative should be issued a supplemental statement of the case (SSOC). (Continued on next page) An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Owen, 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.