Citation Nr: 21075987 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 18-34 297 DATE: December 22, 2021 ORDER The petition to reopen the claim of service connection for an acquired psychiatric disorder is granted. The petition to reopen the claim of service connection for residuals of a stroke is granted. The petition to reopen the claim of service connection for tinnitus is granted. Service connection for an acquired psychiatric disorder is granted. Service connection for residuals of a stroke is denied. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. Service connection for dyslipidemia is denied. Service connection for sleep apnea is denied. Service connection for a skin disorder is denied. Service connection for diabetes mellitus is denied. Service connection for bilateral lower extremity diabetic neuropathy is denied. Entitlement to an effective date earlier than September 2, 2015 for the award of a temporary total rating for convalescence following right knee surgery is denied. REMANDED Service connection for hypertension is remanded. Service connection for diverticulitis is remanded. Service connection for hemorrhoids is remanded. Service connection for a back disorder is remanded. Service connection for a left knee disorder is remanded. Service connection for a bilateral hip disorder is remanded. Service connection for a bilateral ankle disorder is remanded. Entitlement to an initial rating higher than 10 percent prior to September 2, 2015 for the service-connected right knee disability is remanded. Entitlement to an initial rating higher than 30 percent from January 1, 2017 onward for the service-connected right knee disability is remanded. Entitlement to an initial compensable rating for the service-connected right knee scar is remanded. Entitlement to a TDIU is remanded. Entitlement to an effective date earlier than September 2, 2015 for eligibility to DEA is remanded. FINDINGS OF FACT 1. The AOJ denied the Veteran's claims for service connection for an acquired psychiatric disorder, residuals of a stroke, and tinnitus in a March 2005 rating decision. He did not file a timely notice of disagreement, and new and material evidence was not associated with the claims file within one year of the decision, and the decision became final. 2. Since the March 2005 rating decision, the Veteran has submitted new and material evidence in support of his claims for service connection for an acquired psychiatric disorder, residuals of a stroke, and tinnitus. 3. The Veteran's current depressive disorder was caused by his service-connected right knee disability. 4. The Veteran did not have a stroke in service. 5. The Veteran's hearing loss did not manifest in or shortly after service, there is no credible evidence of continuity of symptomatology from service to diagnosis, and his hearing loss is otherwise unrelated to service, to include in-service noise exposure. 6. The Veteran's tinnitus is caused by his hearing loss, which is not service-connected. 7. The Veteran's dyslipidemia is a laboratory result and is not a current disability for VA compensation purposes. 8. The Veteran's sleep apnea did not begin during active service or ADT, it was not aggravated during and by a subsequent period of ADT, and it is otherwise not related to service. 9. The Veteran's skin disorder did not begin during active service or ADT, it was not aggravated during and by a subsequent period of ADT, and it is otherwise not related to service. 10. The Veteran's diabetes mellitus did not begin during active service or ADT, it was not aggravated during and by a subsequent period of ADT, and it is otherwise not related to service. 11. There is no competent evidence of a current bilateral lower extremity diabetic neuropathy disability and service connection for diabetes has been denied. 12. The Veteran was admitted to the hospital for right knee surgery on September 2, 2015 and he was not immobilized by cast prior to this date. CONCLUSIONS OF LAW 1. The March 2005 rating decision denying service connection for an acquired psychiatric disorder, residuals of a stroke, and tinnitus is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. The criteria to reopen the claim of service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 5103A, 5108; 38 C.F.R. § 3.156. 3. The criteria to reopen the claim of service connection for stroke residuals have been met. 38 U.S.C. §§ 5103A, 5108; 38 C.F.R. § 3.156. 4. The criteria to reopen the claim of service connection for tinnitus have been met. 38 U.S.C. §§ 5103A, 5108; 38 C.F.R. § 3.156. 5. The criteria for service connection for an acquired psychiatric disorder as secondary to the service-connected right knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 6. The criteria for service connection for residuals of a stroke have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for service connection for dyslipidemia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 10. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 11. The criteria for service connection for a skin disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 12. The criteria for service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 13. The criteria for service connection for bilateral lower extremity diabetic neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 14. The criteria for an effective date earlier than September 2, 2015 for the award of a temporary total rating for convalescence following right knee surgery have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400, 3.401, 4.30. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1977 to September 1977 and from February 2003 to October 2003, and he had numerous periods of active duty for training (ADT) and inactive duty for training (IADT) service through 2016. The matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision. In May 2021, he had a hearing before the undersigned Veterans Law Judge. The Board notes that it is remanding the claim of service connection for hemorrhoids to search for records pre-1993. This search is not relevant to the service connection claims that have been denied herein, as the dates of diagnoses are documented in the record and well after 1993, and the Veteran alleged the conditions began during or after his 2003 period of active duty. Thus, there is no prejudice to the Veteran to decide these claims. 1. The petition to reopen the claim of service connection for an acquired psychiatric disorder is granted. 2. The petition to reopen the claim of service connection for stroke residuals is granted. 3. The petition to reopen the claim of service connection for tinnitus is granted. The AOJ denied the Veteran's claims for service connection for an acquired psychiatric disorder, residuals of a stroke, and tinnitus in a March 2005 rating decision. He did not file a timely notice of disagreement, and the decision became final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Since the March 2005 rating decision, new evidence has been received that relates his psychiatric diagnoses to his service-connected right knee disability. In October 2015, a VA examiner stated the Veteran's residuals of a stroke were related to service. During the May 2021 Board hearing, the Veteran testified that he was exposed to military noise in service which caused his tinnitus. Because this evidence was not part of the claims file when the AOJ denied his claims in March 2005, and assuming the credibility of his statement for reopening only, the evidence is new and material. See 38 C.F.R. § 3.156 (a); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Justus v. Principi, 3 Vet. App. 510, 513 (1992). Accordingly, the petitions to reopen are granted and the claims are considered reopened. 4. Service connection for an acquired psychiatric disorder is granted. The Veteran seeks service connection for an acquired psychiatric disorder related to service. The Board finds that service connection is warranted for a depressive disorder caused by his service-connected right knee disability. Initially, the Board notes that the Veteran testified in May 2021 that he is being treated for posttraumatic stress disorder (PTSD) from exposure to enemy fire. His service records do not show that he would have been exposed to combat, his medical records do not show a PTSD diagnosis, and his numerous statements made seeking treatment contradict his Board testimony. Accordingly, service connection is not warranted for PTSD. In August 2003, during a period of active duty, the Veteran was treated for stroke-like symptoms. He was ultimately diagnosed with a factitious disorder manifested by intentional production or feigning of left-sided hemiparesis and an adjustment disorder with mixed anxiety and depressed mood. He underwent a VA examination in May 2004 at which time the examiner noted the previous diagnosis but determined there was no evidence of a neuropsychiatric condition due to a stroke. The Veteran had subsequent ADT service, and service medical records (post-2004) and VA treatment records do not show mental health issues until 2013, after his right knee injury. For example, the Veteran explicitly denied seeing a behavioral health provider and experiencing mental health problems on periodic health assessment reports in October 2008, October 2010, and February 2012. He denied mental health concerns in a February 2013 periodic health assessment but indicated experiencing relevant symptoms in the behavioral health section. In January 2014, the Veteran was hospitalized twice for suicidal ideation and diagnosed with major depression. The records show that the Veteran reported he was suicidal because he could not work due to his right knee disability. In psychiatric evaluations from February 2014 and May 2014, the Veteran reported experiencing suicidal ideation and major depression related to his right knee because he cannot work. He was diagnosed with anxiety disorder with depressive features in the May 2014 psychiatric evaluation. In a January 2015 physical profile, it was noted that the Veteran's behavioral health condition was not incurred in the line of duty but "is believed to be a direct result of the deterioration of his physical condition," specifically, his right knee. In November 2015, after filing his claims, the Veteran underwent an integrated disability evaluation. After a review of the Veteran's service records and October 2015 examinations, it was determined that the Veteran had major depressive disorder which fails retention standards and was incurred while entitled to base pay. The narrative summary noted February 2014 as onset based on private psychiatric records that were unavailable for review. A psychiatrist case review was addended to the narrative summary. The psychiatrist noted the Veteran first reported behavioral health related symptoms in 2003. Following his discharge from Walter Reed Hospital in 2003, the Veteran did not receive further behavioral health services until early 2014 when he went to see a civilian psychiatrist. According to the report, the Veteran was unable to work secondary to his right knee disability and "had begun experiencing depression and anxiety as a result of it." The psychiatrist further stated that, in February 2014, he was evaluated by another civilian psychiatrist and again reported experiencing mental health symptoms secondary to medical conditions which impaired his ability to work. In the two years since that time, the psychiatrist documented that the Veteran presented with significant social impairment, including reported decreased efficiency and ability to perform occupational tasks, due to his mental and physical conditions. In December 2015, a Medical Evaluation Board proceedings report documented a diagnosis of major depressive disorder and determined the Veteran failed to meet retention standards. The report noted it onset in February 2014 and was incurred while entitled to base pay. In February 2016, the Physical Evaluation Board found the Veteran unfit to continue military service due to, in part, major depressive disorder. The Veteran underwent a VA mental disorders examination in October 2015 and was diagnosed with major depressive disorder. During a summary of his mental health history, the Veteran reported that he did not receive any psychiatric treatment after Walter Reed discharged him, until 2014, because he felt better during that time. The examiner concluded the Veteran's current mental health disorder was related to service because he was diagnosed with an adjustment disorder at Walter Reed and he was treated for depression, which is the condition he "continues to suffer from at present." The examiner stated that "it is solely based on this evidence of treatment and description found in the [annotated service treatment records], that we render the present opinion." Since this medical opinion was rendered, however, treatment records and lay statements from 2004 onward have been associated with the claims file that relate the Veteran's psychiatric condition to his right knee disability. Specifically, the Veteran consistently denied mental health issues and diagnoses in periodic medical assessments, he did not seek treatment until after his right knee disability, he related his symptoms to his right knee disability, and the Medical Evaluation Board and Physical Evaluation Board found that his condition onset in 2014. The Board thus finds that the October 2015 medical opinion is outweighed by the other evidence. The Board does not find that a remand for another medical opinion is necessary because there is sufficient evidence, including numerous psychiatric evaluations, upon which to base the decision. In sum, the Board finds that the weight of the evidence shows the Veteran has a current depressive disorder that was caused by his service-connected right knee disability, and the claim for service connection is granted. 5. Service connection for residuals of a stroke is denied. The Veteran seeks service connection for residuals of a stroke. The Board finds, however, that service connection is not warranted. In August 2003, the Veteran was hospitalized for headaches, chest pain, and left sensory symptoms. A brain CT scan showed slight fullness without signs of hemorrhage. During his hospital stay, he had one additional episode of chest pain and complete inability to move his left arm or leg which lasted about one-half hour. Cardiac enzymes and ECG test results on admission and after the second episode were normal and his recovery was noted as "somewhat atypical for a CVA." Specifically, nursing staff would see him moving his arm and leg but when he noticed he was being observed or upon evaluation, he would be unable to move either. Subsequent CT scans and a brain MRI were normal, and he was diagnosed with a resolved RIND or atypical migraine and anxiety. After being discharged from the hospital, the Veteran was transferred to Walter Reed in mid-August 2003. A narrative summary was completed in February 2004 based on his treatment at Walter Reed to include evaluations by psychiatry, neuropsychology, internal medicine, physical medicine and rehabilitation, occupational therapy, and physical therapy. When he arrived at Walter Reed, additional CT scans, MRIs, MRAs, and carotid duplex scans were conducted, the results for which were normal and did not explain his paresis symptoms. All examiners determined his abilities and impairment were inconsistent. When perceived to be unobserved, he used his left arm freely. After several weeks of treatment, evaluations, and diagnostic tests, he was diagnosed with a factitious disorder predominantly manifested by feigning of left-sided hemiparesis, left-sided sensory deficits, and cognitive dysfunction. In May 2004, he was afforded a VA examination, the diagnosis for which stated, "neurological examination compatible with a somatoform disorder with compulsion or factitious features as also described on neuropsychological testing done at Walter [Reed] Army Medical Center." In short, the contemporaneous medical records the Veteran did not have a stroke. Instead, he was diagnosed with a factitious disorder predominantly manifested by feigning stroke-like symptoms. The Board has considered the evidence favorable to his claim. His VA treatment records show a history of a cerebrovascular accident. It is unclear, and unlikely, that this condition was entered into the system based upon a review of the Veteran's service treatment records, which clearly show he did not have a stroke in service. Regardless, the problem list in his VA treatment records is not probative evidence of a stroke. Similarly, in October 2015, a VA examiner concluded the Veteran's alleged stroke residuals were related to service because "the occurrence is amply documented in VBMS and the residuals are present as depicted in the evaluation." Notably, the examiner did not address the factitious disorder diagnosis and thus it is unclear and unlikely the examiner thoroughly reviewed the Veteran's service treatment records. A review of the service treatment records is vital in this case where the treatment records show no evidence of a stroke, contrary to the Veteran's allegations. He was examined by numerous specialists at a well-respected military hospital and those records conclusively show he did not have a stroke. Because the VA examiner's opinion and VA treatment records problem list do not address the factitious disorder diagnosis nor indicate a thorough review of the service treatment records, the Board finds that they are not probative evidence of a stroke in service. To the extent the examiner found stroke-like residuals on examination, such findings are irrelevant because a stroke did not occur in service. The Board also considered the February 2015 private medical opinion but finds that it is not persuasive. The examiner opined that the Veteran's stroke was more probable than not secondary to his military service, but he did not provide a rationale nor document which evidence he used to support his conclusion. An adequate medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board therefore finds that the medical opinion is inadequate and did not assign it any probative weight. Finally, to the extent the Veteran contends he had a stroke in service, his contentions are outweighed by the voluminous service treatment records that show the contrary. Moreover, as a layperson, he is not competent to render such a diagnosis. Accordingly, the weight of the competent and credible evidence shows the Veteran did not suffer a stroke in service, and the claim for service connection for residuals of a stroke is denied. 6. Service connection for bilateral hearing loss is denied. 7. Service connection for tinnitus is denied. The Veteran seeks service connection for his hearing loss and tinnitus. He testified that he was exposed to military noise in service and that caused his hearing loss. He further contended it began before he separated from service. The Board finds, however, that the evidence demonstrates that the Veteran's hearing loss and tinnitus did not begin during a period of active duty or ADT service, and the conditions are otherwise not related to service. In May 1993 and March 2000, the Veteran denied hearing loss and ear issues on his report of medical history and his audiological results showed normal hearing in both ears. In November 2002, the Veteran underwent an examination for active duty. He denied hearing loss and ear issues on his report of medical history, but his entrance examination showed hearing loss in both ears. Because subsequent records show significantly improved hearing levels, and as it is more favorable to the Veteran, the Board will assume these results are outliers and presume he was sound at entrance. Following his alleged stroke, in August 2003, the Veteran complained of left-sided hearing loss only. He underwent audiological testing and denied tinnitus at that time. The right ear hearing results were normal, and the examiner concluded the left ear hearing results were invalid because they were inconsistent despite several attempts. After separation from active duty, the Veteran underwent a VA audiological examination in May 2004. His pure tone results were normal, and speech recognition results were unavailable because the Veteran refused to respond for the left ear "even though his hearing [was] normal in this ear." He also reported tinnitus at this time, for which the examiner opined there was "no neurological or otologic[] causes found for alleged tinnitus." In short, the Veteran had normal hearing during and shortly after separation from active duty service. In October 2008, the Veteran underwent an audiological examination for his National Guard service and his results show hearing loss in both ears. A subsequent evaluation was conducted in May 2015, which showed significantly worsened hearing loss in both ears. The Veteran was afforded a VA audiological examination in October 2015. The examiner noted that the Veteran's responses were inconsistent for the left ear during the present examination and were unreliable. The examiner further noted that the Veteran's hearing examinations throughout history have been inconsistent and are not reliable in determining whether hearing loss existed at that time. For that reason, the examiner determined the Veteran's hearing loss was less likely than not related to service. The examiner also concluded the tinnitus was secondary to any hearing loss. The Board also considered the February 2015 private medical opinion but finds that it is not adequate. The examiner opined that the Veteran's diabetes was more probable than not secondary to his military service, but he did not provide a rationale nor document which evidence he used to support his conclusion. An adequate medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board therefore finds that the medical opinion is inadequate and did not assign it any probative weight. After a review of the competent and credible evidence, the Board finds that service connection is not warranted for hearing loss and tinnitus. Because hearing loss and tinnitus are considered "chronic diseases" under 38 C.F.R. § 3.309(a), the Board analyzed entitlement to service connection on a presumptive basis for the periods of active duty only. See 38 C.F.R. §§ 3.303, 3.307, 3.309(a). As discussed above, however, the Veteran had normal hearing long after his 1977 period of active duty and during and after his 2003 period of active duty. Thus, his hearing loss and tinnitus were not chronic in service or within one year after service. To the extent the Veteran claimed left-sided hearing loss in October 2003 and tinnitus in May 2004, the Board finds that his contentions are not probative. His records are rife with examples where he is not a reliable historian or credible source. Specifically, several hearing examinations were invalid because the Veteran answered inconsistently. Further, the Veteran has related several conditions to service in Iraq and Kuwait even though he was never stationed there. Importantly, the Veteran claimed left-sided paralysis where medical providers saw normal mobility when unobserved. Based on the history of inconsistent hearing evaluations and lack of credibility, the Board finds that his statements regarding continuity of symptomatology are not probative. Furthermore, the evidence does not support a claim of direct service connection. Again, his treatment records show that he had normal hearing during and shortly after active duty service. Based on his history of hearing evaluations, lack of credibility, and the VA medical opinion, subsequent hearing examination results are not reliable. Therefore, the Board is unable to determine when his hearing loss began. Regardless, it began well after active duty service and the evidence does not show it began during a period of ADT. Notably, the Veteran has not presented persuasive evidence that suggests his hearing loss and tinnitus are related to service. He has contended that the hearing loss is related to the alleged stroke, which the evidence shows did not occur. Instead, the weight of the evidence shows his hearing loss manifested after service and is unrelated to service, and his tinnitus is related to his hearing loss. Accordingly, after considering the competent and credible evidence, the Board finds that service connection is not warranted, and the claims are denied. 8. Service connection for dyslipidemia is denied. The Veteran seeks service connection for dyslipidemia. Although the record shows that the Veteran has been treated for high cholesterol, this condition is not a disability in and of itself for which VA compensation benefits are payable. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996). A disability for VA compensation purposes refers to an impairment of earning capacity due to a disease or injury. See Allen v. Brown, 7 Vet. App. 439 (1995). Further, the Veteran has not argued that his high cholesterol, on its own, has caused any impairment of earning capacity or other disease or injury for which service connection may be granted. Thus, while high cholesterol may be evidence of underlying disability or may later cause disability, service connection may not be granted for a laboratory finding alone. Accordingly, the Board finds that service connection is not warranted, and the claim is denied. 9. Service connection for sleep apnea is denied. The Veteran seeks service connection for his obstructive sleep apnea. He testified that he was tested for sleep apnea in service because he was having trouble staying awake on duty. The Board finds, however, that the evidence demonstrates that the Veteran's sleep apnea did not begin in service. VA treatment records show that the Veteran first complained of sleep apnea-like symptoms in October 2014. Specifically, he reported that his wife complained he snored very loudly and stopped breathing while sleeping, and he experienced daytime somnolence. He was referred for a sleep study and was diagnosed with obstructive sleep apnea in December 2014. He underwent a VA examination in October 2015, at which time he reported that his sleep apnea symptoms began the year before. The Veteran's military personnel records document his periods of ADT and IADT service through 2016. From September 2013 through February 2015, the evidence does not show that he had any ADT service. The Board finds that his contemporaneous treatment records, statements made seeking treatment, and personnel records contradict his testimony that his sleep apnea began in service and was diagnosed during service, and therefore finds that his testimony is not credible. Instead, the probative evidence shows his sleep apnea did not begin during active service or ADT, nor was aggravated during and by a subsequent ADT period, and the Veteran has not alleged that his sleep apnea is otherwise related to service. The Board also considered the February 2015 private medical opinion but finds that it is not persuasive. The examiner opined that the Veteran's sleep apnea was more probable than not secondary to his military service, but he did not provide a rationale nor document which evidence he used to support his conclusion. An adequate medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board therefore finds that the medical opinion is inadequate and did not assign it any probative weight. After considering the competent and credible evidence, the Board finds that service connection is not warranted, and the claim is denied. Because there is no persuasive evidence that his sleep apnea began during a period of active service or ADT, nor was aggravated during and by a subsequent ADT period, and there was sufficient evidence upon which to decide the claim, VA's duty to obtain a VA medical opinion was not triggered. See McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). 10. Service connection for a skin disorder is denied. The Veteran seeks service connection for his dermatitis. He testified that his skin condition began in 2003 and was caused by chemical exposure during service in Iraq in 2003. The Board finds, however, that the evidence demonstrates that the Veteran's skin disorder is not related to service. Initially, the Board notes that the Veteran's personnel records contradict his testimony that he served in Iraq. Instead, his DD 214 shows that he was stationed in the United Kingdom from March 2003 to September 2003, which accounts for the entirety of his foreign service during that active-duty period. His activation records shows that he was transferred to the United Kingdom to support Operation Enduring Freedom, and other personnel records do not show that he was sent to Iraq. His service treatment records further corroborate this determination, as he experienced the alleged stroke in the United Kingdom and was transferred to Walter Reed for treatment in August 2003. The Board finds that the Veteran's service personnel and medical records contradict his testimony that he served in Iraq and therefore does not find that the Veteran's testimony (that he was exposed to chemicals in Iraq or that his skin disorder began due to such exposure) credible. His service treatment records do not show diagnosis of or treatment for a skin disorder during a period of active duty or ADT nor that his skin condition worsened during a subsequent period of ADT and such worsening was caused by his ADT. See Smith v. Shinseki, 24 Vet. App. 40, 48 (2010). His November 2002 medical examination was normal and his August and September 2003 hospital records from Walter Reed show normal skin assessments. In October 2008 and October 2010 periodic health assessments, the Veteran checked yes to high blood pressure but did not check yes to hives/rash. He also explicitly denied a skin rash in February 2012, February 2013, March 2014, and May 2015 periodic health assessments. Dermatitis was first noted when undergoing evaluations for physical fitness in 2015. Despite indicating that right knee and mental health conditions were incurred while entitled to base pay, such was not noted for the documented dermatitis condition. He was afforded a VA examination in May 2004 for unrelated conditions and only dermatitis associated with roundworm was documented. The Veteran did not report chronic dermatitis that began in service. He underwent another VA examination in October 2015 and a 2011 diagnosis of dermatitis was documented. He reported treating it with a prescription topical corticosteroid. VA and private treatment records do not show treatment for a skin disorder. In short, the evidence does not suggest the Veteran's current dermatitis disorder began in active duty or ADT service, nor was aggravated during and by a subsequent ADT period. The only evidence in support of the Veteran's claims was his own testimony, which the Board finds is not credible. Accordingly, service connection is not warranted, and the claim is denied. Because there is no persuasive evidence that his skin disorder began during a period of active service or ADT and there was sufficient evidence upon which to decide the claim, VA's duty to obtain a VA medical opinion was not triggered. See McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). 11. Service connection for diabetes mellitus is denied. The Veteran seeks service connection for his diabetes mellitus. He testified that he was diagnosed with diabetes in 2003 or 2004. The Board finds, however, that the evidence demonstrates that the Veteran's diabetes did not begin during a period of active duty or ADT service, and is otherwise not related to service. The Veteran underwent a VA examination in August 2004 for other conditions, and laboratory tests from that time show normal glucose levels. A VA treatment record from August 2010 explicitly noted the Veteran was not diabetic. The Veteran underwent a private primary care evaluation on February 3, 2014, at which time hypertension, but not diabetes, was documented in his medical history. Laboratory tests were ordered but the results are not in the record; however, a VA record from February 28, 2014 shows diabetes mellitus in his active problems list. He underwent a VA examination in October 2015, which documented the date of diagnosis as 2014. Thus, VA and private medical records show he was diagnosed with diabetes in approximately February 2014. His service treatment records show similarly. His November 2002 medical examination was normal, and his August and September 2003 Walter Reed hospital records are negative for diabetes. Further, August 2003, December 2003, and July 2010 urinalyses show normal glucose levels. In October 2008 and October 2010 periodic health assessments, the Veteran checked yes to high blood pressure but did not check yes to diabetes. He also explicitly denied diabetes February 2012, February 2013, and March 2014 periodic health assessments, but affirmed diabetes in the May 2015 periodic health assessment. Thus, his records corroborate the Board's determination that he was diagnosed with diabetes in approximately early 2014. The Veteran's military personnel records document his periods of ADT and IADT service through 2016. From September 2013 through February 2015, the evidence does not show that he had any ADT service. In short, the probative evidence shows his diabetes did not begin during active service or ADT, nor was aggravated during and by a subsequent ADT period, and the Veteran has not alleged that his diabetes is otherwise related to service. Notably, while diabetes mellitus is considered a "chronic disease" per 38 C.F.R. § 3.309(a), presumptive service connection is not available when the claim is based on a period of ADT. See Smith, 24 Vet. App. at 47. The Board also considered the February 2015 private medical opinion but finds that it is not adequate. The examiner opined that the Veteran's diabetes was more probable than not secondary to his military service, but he did not provide a rationale nor document which evidence he used to support his conclusion. An adequate medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board therefore finds that the medical opinion is inadequate and did not assign it any probative weight. After considering the competent and credible evidence, the Board finds that service connection is not warranted, and the claim is denied. Because there is no persuasive evidence that his diabetes began during a period of active service or ADT, nor was aggravated during and by a subsequent ADT period, and there was sufficient evidence upon which to decide the claim, VA's duty to obtain a VA medical opinion was not triggered. See McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). 12. Service connection for bilateral lower extremity diabetic neuropathy is denied. The Veteran seeks service connection for bilateral lower extremity diabetic neuropathy. The Veteran's medical records and the April 2016 VA examination are negative for a current disability. Regardless, service connection for diabetes has been denied; therefore, service connection for bilateral lower extremity diabetic neuropathy must also be denied. 13. Entitlement to an effective date earlier than September 2, 2015 for the award of a temporary total rating for convalescence following right knee surgery is denied. The Veteran contends he is entitled to an effective date earlier than September 2, 2015 for the award of a temporary total rating for convalescence following his right knee surgery. During the May 2021 Board hearing, he did not allege that he underwent surgery that met the criteria or that he was immobilized by cast prior to this date. A temporary total rating is assigned when treatment of a service-connected disability results in: (1) surgery necessitating at least one month of convalescence; (2) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. See 38 C.F.R. § 4.30. A temporary total surgical convalescent rating contemplates only a temporary period of time required by a veteran to recover from the immediate effects of surgery. See generally id. Thereafter, any chronic residual disability is evaluated under the schedular criteria for the disability. As to the effective date for a temporary total rating for surgical convalescence, the temporary total rating begins on the date of hospital admission or outpatient treatment and continues for a period of one, two, or three months from the first day of the month following such hospital discharge or outpatient release. See id. Temporary total ratings for surgical convalescence are payable from the date of entrance into the hospital and are awarded after discharge from the hospital. See 38 C.F.R. § 3.401(h)(2). Upon review of the evidence of record, the Board finds that an effective date prior to September 2, 2015 for the assignment of a temporary total rating pursuant is not warranted. Here, the date of the hospital admission for the Veteran's back surgery was September 2, 2015. Thus, that is the proper effective date for his temporary total rating pursuant to 38 C.F.R. § 4.30. The medical and lay evidence does not establish that his knee was immobilized by cast, without surgery, prior to this date. Consequently, an earlier effective date cannot be awarded. Accordingly, the claim is denied. REASONS FOR REMAND 1. Service connection for hypertension is remanded. The Board finds VA's duty to provide a medical opinion has been triggered by the evidence. Specifically, the Veteran's 2003 service records show cardiovascular complaints and high blood pressure readings. While a VA examination was obtained in October 2015, the examiner did not issue a nexus opinion. Thus, a remand is necessary to obtain an addendum medical opinion. 2. Service connection for diverticulitis is remanded. The Board finds that the issue must be remanded for outstanding treatment records and a medical opinion that is based on an accurate factual history and includes a rationale. The Veteran was afforded a VA intestinal conditions examination in October 2015. The examiner documented a diagnosis of diverticulitis from 2003 and noted that the Veteran underwent surgery for it in 2009. The examiner concluded that his diverticulitis began in 2003 utilizing one medical record from August 19, 2003 that documented abdominal pain and diarrhea. The Veteran's remaining medical records from Walter Reed hospital show, however, a normal abdominal status and subsequent service records and statements do not show diverticulitis complaints until after his operation. Thus, the Board finds that a remand is necessary for a medical opinion that includes a rationale. Additionally, the Veteran's operation records are not associated with the claims file and an attempt should be made to find them before a new medical opinion is obtained. 3. Service connection for hemorrhoids is remanded. The Veteran seeks service connection for hemorrhoids. A May 1993 entrance examination shows a past medical history of hemorrhoids, but earlier records are not associated with the claims file. An October 2015 memorandum from the Department of the Army, associated with the Veteran's service records, shows that the Veteran's initial Army entrance medical examination is unavailable for review. It is not shown in the record, however, that the AOJ made its own attempts to obtain records that predate 1993, to include the 1977 entrance examination, and notified the Veteran of their unavailability. Instead, the requests associated with the claims file only include the 2003 active service period. Notably, his personnel records show active service from May 1977 to September 1977 and periods of ADT and IADT from 1976 to 2016. Accordingly, a remand is necessary to attempt to obtain any records that predate 1993. 4. Service connection for a back disorder is remanded. 5. Service connection for a left knee disorder is remanded. 6. Service connection for a bilateral hip disorder is remanded. 7. Service connection for a bilateral ankle disorder is remanded. The Veteran contends that his back, left knee, bilateral hip, and bilateral ankle disorders are secondary to his service-connected right knee disability. While he received examinations for these conditions, medical opinions were not obtained. Accordingly, a remand is necessary. 8. Entitlement to an initial rating higher than 10 percent prior to September 2, 2015 for the service-connected right knee disability is remanded. 9. Entitlement to an initial rating higher than 30 percent from January 1, 2017 onward for the service-connected right knee disability is remanded. 10. Entitlement to an initial compensable rating for the service-connected right knee scar is remanded. The Veteran contends that his right knee and scar have worsened since his last examination. Further, his VA records from 2015 onward are not associated with the claims file. Finally, as the Veteran will undergo a new knee examination, the Board finds that an attempt should be made to obtain a retroactive medical opinion that adequately addresses the factors discussed in Sharp v. Shulkin, 29 Vet. App. 26 (2017) for the period before September 2, 2015. A remand is therefore necessary to obtain updated VA examinations, a medical opinion, and VA treatment records. 11. Entitlement to a TDIU is remanded. 12. The claims for entitlement to an effective date earlier than September 2, 2015 for eligibility to DEA is remanded. Entitlement to a TDIU and an earlier effective date for DEA eligibility are inextricably intertwined with the remanded issues and must be remanded as well. The matters are REMANDED for the following action: 1. Obtain the Veteran's complete service treatment records from 1976 to1993, to include documents pertaining his active duty service from May 1977 to September 1977 and his service in the Puerto Rico National Guard. Document all requests for information as well as all responses in the claims file. 2. Obtain the Veteran's San Juan VAMC treatment records from December 2015 onward. 3. Ask the Veteran to complete a VA Form 21-4142 for any physicians who treated his diverticulitis, to include surgeries. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 4. Only proceed to the next instructions after all records have been requested and/or obtained. 5. Forward the claims file to a VA examiner for a medical opinion regarding the Veteran's hypertension claim. An in-person examination is unnecessary unless determined otherwise by the examiner. After a review of the claims file, the examiner should respond to the following: Is it at least as likely as not that the Veteran's hypertension began in service in 2003? The examiner should consider the Veteran's August 2003-October 2003 service treatment records and Walter Reed hospital records showing high blood pressure readings when rendering the opinion (multiple documents, received June 17, 2015, titled STR Medical Photocopy). 6. Forward the claims file to a VA examiner for a medical opinion regarding the Veteran's diverticulitis claim. An in-person examination is unnecessary unless determined otherwise by the examiner. After a review of the claims file, the examiner should respond to the following: Is it at least as likely as not that the Veteran's diverticulitis began in service in 2003 or is otherwise related to that service? The examiner should consider any new private records received regarding his diverticulitis operation and the positive VA opinion rendered in October 2015 (received in the claims file on November 1, 2015). The examiner should provide a rationale explaining the conclusion. If the examiner disagrees with the October 2015 medical opinion, the examiner should explain why. 7. Forward the claims file to an appropriate VA examiner to assess the current severity of the Veteran's right knee musculoskeletal disability and right knee scar disability. In addition to those examinations, the examiner should respond to the following: Review the October 2015 VA examination findings, and provide a retrospective medical opinion (if practicable) as to: i. Whether additional functional loss resulted due to pain, weakness, excess fatigability, coordination, flare-ups and/or repeated use during these examinations. If feasible, the examiner should assess the additional functional impairment in terms of degree of additional range of motion loss. ii. If the examiner is unable to provide the requested opinion, please clearly explain why. 8. Schedule the Veteran for a VA examination to assess the nature and etiology of his back, left knee, bilateral hip, and bilateral ankle disorders. After a review of the claims file, to include updated VA treatment records, the examiner should respond to the following: Is it at least as likely as not that the Veteran's back disorder is caused by or aggravated by his service-connected right knee disability? Is it at least as likely as not that the Veteran's left knee disorder is caused by or aggravated by his service-connected right knee disability? Is it at least as likely as not that the Veteran's bilateral hip disorder is caused by or aggravated by his service-connected right knee disability? Is it at least as likely as not that the Veteran's bilateral ankle disorder is caused by or aggravated by his service-connected right knee disability? MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Lavan 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.