Citation Nr: 21012101 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 14-32 851 DATE: March 3, 2021 ORDER Entitlement to an effective date prior to December 31, 2015, for a grant of service connection for tinnitus is denied. Entitlement to an effective date prior to December 31, 2015, for service connection for a left knee disability based on limitation of extension is denied. Entitlement to an effective date prior to December 31, 2015 for an increased 30 percent rating for irritable bowel syndrome (IBS) is denied. Entitlement to an effective date prior to March 19, 2015 for an increased 10 percent rating for a right ankle disability is denied. Entitlement to a rating in excess of 10 percent for tinnitus is denied. Entitlement to a compensable rating for pseudofolliculitis barbae (PSB) is denied. Entitlement to a rating in excess of 30 percent for irritable bowel syndrome (IBS) is denied. Entitlement to a compensable rating for maxillary sinusitis is denied. Entitlement to an initial compensable rating for a left knee disability, based on limitation of extension of left knee is denied. Entitlement to an initial disability rating in excess of 10 percent for left knee patellofemoral syndrome is denied. Entitlement to an initial 20 percent rating under Diagnostic Code 5258, for left knee meniscal tear with frequent episodes of joint pain is granted. Entitlement to service connection for hypertension is granted. Entitlement to a total disability rating based on individual unemployability is granted. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a bilateral foot condition is remanded. Entitlement to a rating in excess of 10 percent for a right ankle disability is remanded. Entitlement to service connection for fibromyalgia, to include as due to an undiagnosed illness is remanded. Entitlement to service connection for a sleep disorder, claimed as chronic fatigue syndrome, to include as due to an undiagnosed illness is remanded. Entitlement to service connection for unspecified joint pain, to include as due to an undiagnosed illness is remanded. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a left hip disability is remanded. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a left shoulder disability is remanded. Whether new and material evidence has been received to reopen a previously denied claim for service connection for body aches and pains, to include as due to an undiagnosed illness is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for costochondritis and dehydration, claimed as chest pains is remanded. Entitlement to service connection for shaking spells is remanded. FINDINGS OF FACT 1. The RO received the Veteran’s intent to file a claim of service connection for a tinnitus on December 31, 2015; this was the earliest statement received by VA expressing a desire or intention to seek such benefits. 2. The RO received the Veteran’s intent to file a claim for an increased rating for a left knee disability on December 31, 2015, which resulted in a grant of service connection for limitation of extension of the left knee; this was the earliest statement received by VA expressing a desire or intention to seek such benefits. 3. The RO received the Veteran’s intent to file a claim for an increased rating for IBS on December 31, 2015; this was the earliest statement received by VA expressing a desire or intention to seek such benefits. It is not factually ascertainable that an increase in his IBS occurred during the one-year period prior to his claim. 4. The RO received the Veteran’s intent to file a claim for an increased rating for a right ankle disability on December 31, 2015; this was the earliest statement received by VA expressing a desire or intention to seek such benefits. It is not factually ascertainable that an increase in the Veteran’s right ankle disability occurred prior to March 19, 2015. 5. The Veteran's service-connected tinnitus has been assigned the maximum 10 percent schedular rating. 6. At no time during the rating period on appeal has the Veteran's pseudofolliculitis barbae skin disability been manifested by characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body or exposed areas, or treatment with systemic therapy for a total duration of less than six weeks during the past 12-month period. 7. The Veteran’s IBS has been assigned the maximum 30 percent rating; and the Veteran's symptoms are adequately contemplated under this rating. 8. The Veteran’s maxillary sinusitis was manifested by one non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting; there was no evidence of incapacitating episodes requiring prolonged antibiotic treatment. 9. Flexion of the Veteran’s left knee, even with pain and after repetitive testing, is greater than 30 degrees. 10. Extension of the Veteran’s knee, even with pain and after repetitive testing, is not limited to 10 degrees. 11. The evidence establishes that the Veteran's left knee disability manifested in symptoms approximate to a left knee meniscus tear (semilunar cartilage), with effusion and frequent episodes of joint pain. 12. Symptoms of hypertension were chronic during active service and have been continuous since service separation. 13. The Veteran’s service-connected disabilities render him unable to secure or follow substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to December 31, 2015, for a grant of service connection for tinnitus have not been met. 38 U.S.C. § 1155; 38 U.S.C. §§ 5110, 5107; 38 C.F.R. § 3.400. 2. The criteria for an effective date prior to December 31, 2015, for service connection for a left knee disability based on limitation of extension have not been met. 38 U.S.C. § 1155; 38 U.S.C. §§ 5110, 5107; 38 C.F.R. § 3.400. 3. The criteria for an effective date prior to December 31, 2015, for an increased 30 percent rating IBS have not been met. 38 U.S.C. § 1155; 38 U.S.C. §§ 5110, 5107; 38 C.F.R. § 3.400. 4. The criteria for an effective date prior to March 19, 2015, for an increased 10 percent rating for a right ankle disability have not been met. 38 U.S.C. § 1155; 38 U.S.C. §§ 5110, 5107; 38 C.F.R. § 3.400. 5. The criteria for a rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.118, Diagnostic Code (DC) 4.87, DC 6260 6. The criteria for a compensable rating for pseudofolliculitis barbae skin disability have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.118, Diagnostic Code (DC) 7806. 7. The criteria for an initial rating in excess of 30 percent for IBS have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.114, Diagnostic Code (DC) 7319. 8. The criteria for a compensable rating for maxillary sinusitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.97, Diagnostic Code (DC) 6513. 9. The criteria for an initial compensable rating for a left knee disability, based on limitation of extension have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260 and 5261. 10. The criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260 and 5261. 11. The criteria for an initial 20 percent rating under Diagnostic Code 5258 for a left knee meniscus tear (semilunar cartilage), with effusion and frequent episodes of joint pain have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5258. 12. The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 13. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.340, 3.341, 4.1, 4.3, 4.15, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1989 to February 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from various rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The appeals herein have been merged for purposes of judicial economy and efficiency. The Veteran testified at a hearing before the undersigned Veterans Law Judge in April 2017. A transcript of the hearing has been associated with the record. In September 2020, the Veteran submitted additional evidence, which has not yet been considered by the RO. However, the Veteran waived initial RO consideration of that evidence. Earlier Effective Date 1. Entitlement to an effective date prior to December 31, 2015, for a grant of service connection for tinnitus 2. Entitlement to an effective date prior to December 31, 2015, for a grant of service connection for a left knee disability based on limitation of extension The law provides that the effective date for an award of service connection is the day following separation from active duty, or the day entitlement arose, if the claim is filed within the year after active duty. When the claim is filed more than a year after active duty, the effective date for service connection will be the date of VA receipt of the claim, or date entitlement arose, whichever is later. 38 U.S.C. § 5110(a), (b)(1); 38 C.F.R. § 3.400(b)(2). A claim for VA benefits, whether formal or informal, must be in writing and must identify the benefit sought. 38 U.S.C. § 5101; 38 C.F.R. §§ 3.1(p), 3.151, 3.155; Rodriguez v. West, 189 F.3d 1351 (Fed. Cir. 1999); Lalonde v. West, 12 Vet. App. 377 (1999). Treatment records by themselves do not constitute 'informal claims' for service connection. Sears v. Principi, 16 Vet. App. 244 (2002). While VA should broadly interpret submissions from a veteran, it is not required to conjure up claims not specifically raised. Brannon v. West, 12 Vet. App. 32 (1998). A January 2016 letter indicates that VA first received the Veteran’s intent to file a claim on December 31, 2015. The Veteran then filed a formal claim for the above-captioned matters in June 2016. In an October 2016 rating decision, the Veteran was awarded service connection for tinnitus, service connection for a left knee disability based on limitation of extension, an increased 30 percent rating for IBS, and an increased 10 percent rating for a right ankle disability; all effective June 20, 2016. In a November 2016 rating decision, the Veteran was granted an earlier effective date of December 31, 2015, for the above-captioned claims; based on a finding that the RO made a clear and unmistakable error by failing to assign the effective date as the date VA received the Veteran’s intent to file a claim. The Veteran alleges on his September 2017 Notice of Disagreement that he is entitled to an earlier effective date for each claim. However, no argument supporting this contention has been proffered by the Veteran or his attorney. The Board has carefully reviewed all documents in the Veteran's claims file and finds there is no evidentiary basis for the assignment of an earlier effective date. The controlling law and regulations regarding effective dates are clear. The effective date of an award of compensation based on an original claim (received beyond one year after discharge), will be the date of VA receipt of the claim, or date entitlement arose, whichever is later. 38 U.S.C. § 5110(a), (b)(1); 38 C.F.R. § 3.400(b)(2). In this case the Veteran’s intent to file a claim was received on December 31, 2015. No earlier correspondence can be construed as either a notice of intent to file a claim or a claim for entitlement to service connection or an increased rating for the above-captioned conditions. Thus, the effective date was properly assigned as the date of the intent to file a claim. Accordingly, the claims for earlier effective dates are denied. 3. Entitlement to an effective date prior to December 31, 2015, for an increased 30 percent rating for irritable bowel syndrome (IBS) The Veteran contends that an effective date prior to December 31, 2015 is also warranted for the increased 30 percent rating for IBS. Likewise, no argument supporting this contention has been proffered by the Veteran or his attorney. For increases, the effective date will be the receipt of the claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o). The effective date of an increase in disability compensation is the earliest date as of which it is factually ascertainable that an increase in disability had occurred if the claim is received within one year from such date. Otherwise, the effective date is the date of receipt of the claim. 38 C.F.R. § 3.400(o)(2). If an increase in disability occurred within one year prior to the claim, the increase is effective as of the date the increase was "factually ascertainable." If the increase occurred more than one year prior to the claim, the increase is effective the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. 38 U.S.C. § 5110(b)(2); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. § 3.400(o)(1)(2); VAOPGCPREC 12-98 (1998). Effective dates "should not be assigned mechanically based on the date of diagnosis." Swain v. McDonald, 27 Vet. App. 219, 224 (2015). Instead, "all the facts should be examined" to determine the date the increase in disability first manifested. DeLisio v. Shinseki, 25 Vet. App. 45, 58 (2011). As the effective date assigned for the Veteran’s IBS is December 31, 2015, the date the intent to file was received, the remaining inquiry for the Board is if it is factually ascertainable that the increase in disability occurred at some point within one year prior to the claim. The Veteran’s VA and private treatment records contain no entries addressing the severity of the Veteran’s IBS in the year prior to December 31, 2015. Likewise, no VA examination addressing the disability was conducted during this period. Thus, there is no evidence addressing the state of the Veteran's IBS from December 31, 2014 to December 31, 2015, and therefore an earlier effective date cannot be granted on that basis. For these reasons, an effective date earlier than December 31, 2015 cannot be granted for the Veteran's IBS. 4. Entitlement to an effective date prior to March 19, 2015, for an increased 10 percent rating for a right ankle disability The Veteran contends that an effective date prior to March 19, 2015 is also warranted for the increased 10 percent rating for a right ankle disability. Likewise, no argument supporting this contention has been proffered by the Veteran or his attorney. While the Veteran’s intent to file was received on December 31, 2015, the effective date assigned for the Veteran’s 10 percent right ankle rating is March 19, 2015; the date that it was factually ascertainable that an increase in the Veteran’s right ankle disability occurred. Notably, a March 2015 VA treatment record showed a decreased range of motion in the Veteran’s right ankle with pain; meeting the criteria for the assigned 10 percent rating. As noted above, if an increase in disability occurred within one year prior to the claim, the increase is effective as of the date the increase was "factually ascertainable." 38 U.S.C. § 5110(b)(2). As the Veteran’s intent to file was received on December 31, 2015, the earliest effective date possible for the Veteran’s increased 10 percent rating is December 31, 2014. Thus, the remaining inquiry for the Board is if it is factually ascertainable that the increase in disability occurred between the period of December 31, 2014 and March 19, 2015. The Veteran’s VA and private treatment records contain no entries addressing the severity of the right ankle between December 31, 2014 and March 19, 2015. Likewise, no VA examination addressing the disability was conducted during this period. Thus, there is no evidence addressing the state of the Veteran's right ankle disability from December 31, 2014 to March 19, 2015, and therefore an earlier effective date cannot be granted on that basis. For these reasons, an effective date earlier than March 19, 2015, cannot be granted for the Veteran's right ankle disability. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The Schedule is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When two evaluations are potentially applicable, VA will assign the higher evaluation when the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. VA will resolve reasonable doubt as to the degree of disability in favor of the Veteran. 38 C.F.R. § 4.1. If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). As a result, a complete medical history of the Veteran is required for a ratings evaluation. This is in order to protect claimants against adverse decisions based on a single, incomplete, or inaccurate report, and to enable VA to make a more precise evaluation. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, VA has a duty to acknowledge and consider all regulations which are potentially applicable, and to explain the reasons and bases for its conclusions. 5. Entitlement to a rating in excess of 10 percent for tinnitus The pertinent rating criteria provides a maximum rating of 10 percent for recurrent tinnitus. 38 C.F.R. §4.87, DC 6260. In Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006), the United States Court of Appeals for the Federal Circuit found that 38 C.F.R. § 4.25(b) and 38 C.F.R. § 4.87, DC 6260, limits a Veteran to a single rating for tinnitus, regardless of whether the tinnitus is unilateral or bilateral. The Veteran's service-connected tinnitus has been assigned the maximum schedular rating available for tinnitus, 10 percent, during the entire appeal. 38 C.F.R. §4.87, DC 6260. As there is no legal basis upon which to award separate schedular evaluations for tinnitus in each ear, or any rating in excess of 10 percent for tinnitus, the Veteran's appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). 6. Entitlement to a compensable rating for pseudofolliculitis barbae (PFB) The Veteran asserts that he is entitled to a compensable rating for his pseudofolliculitis barbae (PFB) disability. He is currently in receipt of a non-compensable rating under DC 7806. Board notes that during the pendency of this appeal, effective August 13, 2018, VA amended Diagnostic Code 7806, in part, to include a definition of "systematic therapy" as treatment administered through any route other than the skin. However, the former rating criteria, which did not define "systematic therapy," are applicable to claims that were pending prior to the effective date of the new rule, when it is more favorable to a Veteran. Burton v. Wilkie, 30 Vet. App. 286 (2018) (citing Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). In this regard, the Board notes that the Veteran's claim was pending prior to August 13, 2018, so that the prior and amended versions of Diagnostic Code 7806 are applicable to this case, depending on which version is more favorable to the Veteran. The Board will consider the Veteran's claim under both the old and new rating criteria, and the more favorable criteria will be applied. As stated, Diagnostic Code 7806 was amended in August 2018. Prior to the August 2018 amendment, a noncompensable rating is warranted if the condition is manifested on less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating is warranted if the skin condition is manifested on at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted if the skin condition is manifested on 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted if the skin condition is manifested on more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Under the amended Diagnostic Code 7806, a rating is determined using the General Rating Formula for Skin. Under the General Rating Formula for Skin, a noncompensable rating is warranted if the skin condition requires no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is warranted if the skin condition is manifested by one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is warranted if the skin condition is manifested by at least one of the following: characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or Systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is warranted if the skin condition is manifested by at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed area affected; or constant or near-constant systemic therapy including, but not limited to corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. Where a law or regulation changes during the pendency of a case, the version most favorable to the appellant will generally be applied. See West v. Brown, 7 Vet. App. 70, 76 (1994), Hayes v. Brown, 5 Vet. App. 60, 66 67 (1993), Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). The VA General Counsel has held that where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the Veteran had prior to enactment of the new rule. See VAOPGCPREC 7-2003 (Nov. 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g), can be no earlier than the effective date of that change. VA can apply only the earlier version of the regulation for the period prior to the effective date of the change. There have been no specific arguments presented as to which version of the criteria should apply, but the Board finds that the previous version is broader as it does not require the presence of characteristic lesions. Regarding the meaning of systemic therapy under the previous criteria, in Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the Federal Circuit determined that constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs under the previous DC 7806 is generally not inclusive of topical corticosteroids. Instead, systemic therapy means treatment pertaining to or affecting the body as a whole,' whereas topical therapy means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied'. Johnson, 862 F.3d at 1355. The Federal Circuit concluded that the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of the case. Id., at 1356. This interpretation of the term systemic therapy applies prior to the August 13, 2018, effective date of the new criteria. Jordan v. Nicholson, 401 F.3d 1296, 1298-99 (Fed. Cir. 2005) (noting that a new interpretation of a statute retroactively affects decisions still open on direct review). The United States Court of Appeals for Veterans Claims (Court/CAVC) again addressed systemic therapy in the context of topical treatment in Burton v. Wilkie, 30 Vet. App. 286 (2018). The Burton Court stated that, when considering topical therapy as systemic therapy, the Federal Circuit Court's Johnson decision was not limited to situations involving large-scale application of topical treatment. Id. at 291. Rather, the Court held that there are at least two other potential ways of showing that a topical treatment is systemic: (1) the method by which the topical treatment works, and (2) its side effects. Id. Turning to the medical evidence, the Veteran was afforded a VA examination in November 2016. At the time, he reported a history of PFB since service that he currently controlled by not shaving. There was no evidence of disfigurement of the head, face, or neck. The examiner noted that the Veteran did not treat the condition with any oral or topical medication in the prior 12 months. The Veteran also denied treatments or procedures other than systemic or topical medications. Less than 5 percent of the Veteran’s exposed areas or total body areas were affected. The examiner indicated that the Veteran’s PFB was well controlled with limiting shaving, that his diagnosis remained the same, and his disease had not progressed. The Veteran’s VA treatment records, private treatment records, or any lay evidence of record indicates that his PFB affects at least 5 percent of his exposed areas or total body areas, or that he treats the condition in any way. When both the current and former criteria is considered for rating the Veteran's pseudofolliculitis barbae disability, the Veteran is not eligible for a compensable rating under either version of diagnostic code 7806. With respect to the current amended criteria of the diagnostic code, the Veteran did not experience a skin condition manifested by characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent of exposed areas affected; nor did he require intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than six weeks over the past 12-month period. With respect to the previous criteria set forth in Diagnostic Code 7806, the Veteran's skin condition was not manifested on at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, nor was intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. Therefore, the Veteran is not entitled to a compensable rating under either the amended or former version of diagnostic code 7806. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable and the appeal for a compensable rating for pseudofolliculitis barbae is denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 7. Entitlement to a rating in excess of 30 percent for irritable bowel syndrome (IBS) The Veteran contends that a rating in excess of 30 percent is warranted for his service-connected IBS. Under 38 C.F.R. § 4.114, DC 7319, irritable bowel syndrome is rated as 10 percent disabling if the condition is moderate with frequent episodes of bowel disturbance with abdominal distress. A maximum 30 percent rating is assigned for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. The 30 percent rating currently assigned for IBS is the maximum assignable rating under DC 7319, and there are no other potentially applicable Diagnostic Codes relevant to the Veteran's IBS symptoms. As such, a schedular rating in excess of 30 percent for IBS cannot be assigned. Moreover, the Veteran's symptoms are adequately contemplated in the currently assigned rating. 8. Entitlement to a compensable rating for maxillary sinusitis The Veteran contends that a compensable rating is warranted for his service-connected maxillary sinusitis. The condition is currently rated as noncompensable under Diagnostic Code 6513. Under Diagnostic Code 6513, sinusitis warrants a noncompensable evaluation when there is evidence of chronic maxillary sinusitis detected by x-ray only. A 10 percent rating is warranted when there are one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is warranted when there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent disability rating is warranted following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A note following these rating criteria indicates that an "incapacitating episode" of sinusitis means one that requires bed rest and treatment by a physician. Id. The Veteran was afforded a VA examination in March 2015. The examiner noted a diagnosis of chronic sinusitis. The Veteran reported a runny nose, colds, and sinus headaches. He indicated that his current symptoms were the same as during service. On physical examination, the Veteran’s maxillary sinus was noted to be affected by his chronic sinusitis diagnosis. The Veteran’s symptoms attributable to condition were chronic sinusitis detected only by imaging studies, headaches, tenderness of affected sinus, and facial grimaces exhibited upon percussion of maxillary sinuses. The Veteran denied non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months. The Veteran also denied incapacitating episodes of sinusitis requiring prolonged use of antibiotics treatment in the past 12 months. There was also no history of sinus-related surgical procedures. The Veteran was also afforded a VA examination in September 2016. The examiner noted a diagnosis of chronic sinusitis. The Veteran reported sinus headaches that were treated with over the counter medication and spray. He indicated that his current symptoms were the same as during service. On physical examination, the Veteran’s maxillary sinus was affected by his chronic sinusitis diagnosis. The Veteran’s symptoms attributable to chronic sinusitis were chronic sinusitis detected only by imaging studies, headaches, and tenderness of affected sinus. The Veteran reported one non-incapacitating episode of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months. The Veteran denied incapacitating episodes of sinusitis requiring prolonged use of antibiotics treatment in the past 12 months. There was also no history of sinus-related surgical procedures. Based on the evidence, the Board finds that the Veteran's chronic sinusitis more nearly approximates the criteria for a noncompensable rating. The Veteran consistently denied incapacitating episodes requiring prolonged antibiotic treatment and reported only one non-incapacitating episode characterized by headaches, pain, and purulent discharge or crusting. Thus, the evidence is insufficient to support a higher disability rating for the Veteran's sinusitis. The benefit of the doubt rule is not applicable and the appeal for a compensable rating for sinusitis is denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 9. Entitlement to an initial compensable rating for a left knee disability, based on limitation of extension of left knee is denied. 10. Entitlement to an initial disability rating in excess of 10 percent for left knee patellofemoral syndrome is denied and an initial 20 percent rating under Diagnostic Code 5258 for a left knee meniscus tear (semilunar cartilage), with effusion and frequent episodes of joint pain is granted. The Veteran contends that his left knee disability warrants higher ratings than the currently assigned noncompensable rating for limitation of extension and the 10 percent rating for patellofemoral syndrome. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997); 38 C.F.R. § 4.59. Limitation of motion of the knees is rated under Diagnostic Codes 5260, and 5261. Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5260, a noncompensable rating is assigned when flexion of the leg is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. In addition, under Diagnostic Code 5258, a single rating of 20 percent is available where there is cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. When evaluating musculoskeletal disabilities based on limitation of motion, the Veteran is entitled to at least the minimum compensable evaluation if motion is accompanied by pain. See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Additionally, VA's General Counsel has also stated that separate ratings under DC 5260 and DC 5261 may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). The Veteran is currently in receipt of a noncompensable rating under 5261 for limitation of extension of the left knee. He is also in receipt of a 10 percent rating for patellofemoral syndrome under DC 5260 based on painful motion of the left knee. The medical evidence of record for this period includes VA examinations conducted in March 2015, September 2016, and June 2018, as well as VA and private treatment records. At the time of the March 2015 examination, the Veteran reported constant daily pain in the left knee that was an 8/10 in severity. He denied flare ups of the knee, but reported swelling and issues with prolonged standing, prolonged walking, and squatting. On range of motion (ROM) testing, flexion of the Veteran’s knee was to 100 degrees and there was full extension. While pain was noted on flexion, it did not cause functional loss. The examiner noted evidence of pain with weight-bearing and crepitus, but there was no objective evidence of localized tenderness or pain on palpation of the joint. There was no loss of ROM after repetitive use. The examiner indicated that she was unable to say without mere speculation whether pain, weakness, fatigability or incoordination significantly limited the Veteran’s functional ability with repeated use over a period of time. The examiner added that the Veteran exhibited difficulty in changing position from sitting to standing. There was no evidence of instability of the knee, muscle atrophy, or meniscal conditions. As to functional impact, the examiner noted that the left knee disability affected prolonged standing, prolonged walking, and caused difficulty with squatting. At the time of the September 2016 examination, the Veteran reported constant daily pain in the left knee that was an 8/10 in severity during the day and 10/10 at night. He reported nightly flare-ups of the knee that caused sleep disturbance. The examiner noted diagnoses of left knee meniscus tear and left knee patellofemoral syndrome. ROM testing of the Veteran’s knee measured 5 to 100 degrees. Pain was noted on flexion of the knee which caused functional loss. There was evidence of pain with weight-bearing, crepitus, and tenderness to palpation of the knee. On repetitive use testing, ROM of the Veteran’s knee measured 5 to 90 degrees. The examiner indicated that she was unable to say without mere speculation whether pain, weakness, fatigability or incoordination significantly limited the Veteran’s functional ability with repeated use over a period of time or on flare-up. The examiner noted that additional contributing factors of the Veteran’s left knee disability were disturbance of locomotion, interference with sitting, and interference with standing. On muscle strength testing, flexion of the Veteran’s knee showed active movement against some resistance. There was no evidence of instability of the knee, muscle atrophy, or meniscal conditions. As to functional impact, the examiner noted that the Veteran reported difficulty with prolonged standing, prolonged walking, and that his knee is unstable causing him to nearly fall. The examiner noted that since a May 2012 examination, the Veteran’s knee disability showed a decrease in ROM and increase in pain. At the time of the June 2018 examination, the examiner noted diagnoses of a left knee meniscus tear, diagnosed in 2012, and left knee patellofemoral syndrome. The Veteran did not report flare-ups of the knee. ROM testing of the Veteran’s knee measured 0 to 90 degrees. Pain was noted on flexion and extension of the knee, but did not cause functional loss. There was no evidence of pain with weight-bearing or crepitus, but tenderness or pain was noted on the medial joint line. On repetitive-use testing there was no loss of ROM of the left knee. Pain, weakness, fatigability or incoordination significantly limited the Veteran’s functional ability after repeated use. No findings were reported regarding flare-ups of the knee, as the Veteran denied any flare-ups. The examiner noted that additional contributing factors of the Veteran’s left knee disability were disturbance of locomotion, interference with sitting, and interference with standing. All muscle strength testing of the Veteran’s knee was normal. There was no evidence of instability of the knee or muscle atrophy. The examiner noted a moderate to large effusion that limited flexion of the knee. With regards to a meniscus (semilunar cartilage) condition, the examiner noted a left side meniscal tear and frequent episodes of joint pain. The functional limitation caused by the Veteran’s left knee was limited stand and walk tolerance. The examiner further noted that there was no evidence of pain on passive ROM testing or when the joint is used in non-weight bearing. Based on the evidence of record, the Board finds that evaluations in excess of the currently assigned 10 percent and noncompensable ratings are not warranted for limitation of motion of the Veteran’s left knee. Objective findings from the Veteran's VA examinations are consistent with the currently assigned 10 percent and noncompensable evaluations, but no greater. Flexion, even with pain and after repetitive testing, is greater than 30 degrees. Likewise, extension is not limited to 10 degrees. Deluca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.59. The Board does, however, find that a 20 percent rating is warranted under Diagnostic Code 5258. As noted by the June 2018 examiner, a June 2012 MRI showed a left side meniscal tear, with a moderate to large effusion, and frequent episodes of joint pain. In this case, the 20 percent rating under DC 5258 will replace the current 10-percent rating under DC 5260 based on painful motion of the left knee. See, e.g., 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Under DC 5258, a 20-percent rating is warranted for symptoms that include locking and pain, which are symptoms that limit motion and therefore likewise fall within the category of limitation of motion. Additionally, the June 2018 examiner noted that the moderate to large effusion limited flexion of the knee. Thus, if a rating under DC 5258 were awarded along with the present 10-percent rating under DC 5260, the Veteran would be compensated twice for symptoms creating pain and limitation of range of motion in the knee. Such double-payment, which is referred to as "pyramiding," is prohibited by the regulations, and therefore VA cannot award both ratings simultaneously. 38 C.F.R. § 4.14. Because the rating under DC 5258 results in the highest rating for the Veteran, it is the rating that the Board will assign. See, e.g., Bradley v. Peake, 22 Vet. App. 280, 294 (2008). The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). However, evaluation of the relevant evidence of record reflects that the record contains no evidence of ankylosis, instability or subluxation, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5257, 5259, 5262, and 5263 do not apply. For the reasons stated above, the Board finds that an increased 20 percent rating under DC 5258 is warranted for the Veteran’s left knee disability. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the claimed in-service disease or injury and the present disability. See, e.g., Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 11. Entitlement to service connection for hypertension The Veteran contends that service connection for hypertension is warranted. Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. For chronic diseases, to include hypertension consider cardiovascular-renal disease, chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more on at least three different days. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2017). The Veteran’s VA treatment records show a confirmed diagnosis of hypertension as early as November 2000. Likewise, private treatment records as recent as March 2020 show a current diagnosis of hypertension. The Board finds that the evidence is at least in equipoise on the question of whether there was an onset of symptoms of elevated blood pressure later diagnosed as hypertension, that were chronic in service and have been continuous since service separation. Service treatment records reflect multiple episodes of mildly elevated blood pressure readings during service, to include elevated blood pressure readings of 160/98, 172/115, and 150/96 in October 1991; 154/90 in August 1991; 151/90 in in October 1992; and 168/116 in October 1992. At the time of the Veteran’s September 1992 separation examination, he checked the box corresponding to “don’t know” in relation to whether he had high or low blood pressure. The post-service medical evidence of record also shows a history of elevated blood pressure readings. Immediately following service, the Veteran had elevated blood pressure readings in April 1993, November 1993, and a notation of possible hypertension in July 1995; culminating in a confirmed diagnosis of hypertension in November 2000. For these reasons, and resolving reasonable doubt in the Veteran's favor, based on the onset of elevated blood pressure readings during service, and continuous post-service symptoms of hypertension since service separation, the Board finds that presumptive service connection for hypertension is warranted under 38 C.F.R. § 3.303(b). 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 12. Entitlement to a TDIU A total disability evaluation may be assigned when the schedular evaluation is less than 100 percent where a Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The term unemployability, as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. See VAOPGCPREC 75-91 (Dec. 17, 1991). The issue is whether a veteran’s service-connected disability or disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a living wage). See Moore v. Derwinski, 1 Vet. App. 356 (1991). In a claim for a TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that a veteran’s service-connected disability or disabilities do not prevent him from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995) (citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994)). The Court has held that the central inquiry in determining whether a Veteran is entitled to a TDIU is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). In determining whether a Veteran is unemployable for VA purposes, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). A Veteran need not show 100 percent unemployability in order to be entitled to a TDIU. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). Pertinently, the Veteran is service connected for depressive disorder which is currently 60 percent disabling; migraine headaches rated as 30 percent disabling; IBS rated as 30 percent disabling; and a lumbar spine disability rated as 20 percent disabling. The Veteran is also service connected for several other disabilities, resulting in a combined 90 percent rating. Accordingly, the Veteran meets the schedular criteria noted above. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The remaining inquiry is whether he is unable to secure or follow a substantially gainful occupation due solely to his service-connected disabilities. The Veteran reports his highest level of education as completing two years of college. The evidence of record shows that he last worked as a laborer at naval base in April 2001. Previously, the Veteran also worked as a gardener. The Veteran reports that all his service-connected conditions contribute to his inability to secure or follow a substantially gainful occupation. At the time of an August 2010 examination, the Veteran was noted to have ongoing moderately severe depression with substance abuse that was determined to be related to the condition. The Veteran reported chronic sleep impairment, difficulty with short-term memory, and impaired impulse control. The examiner noted that the Veteran’s condition caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. At the time of a March 2015 examination, the Veteran’s left knee disability was noted to cause functional impairment due to an inability to run or stand for prolonged periods. A March 2015 examination regarding the Veteran’s headaches noted that he suffered from 3-4 headaches per week with 10/10 intensity. The Veteran reported having to cease any activity until the headache passed. At the time of a September 2016 examination, the Veteran’s left knee disability was reported to cause difficulty walking, standing, and sitting for more than 10 minutes, with the need for breaks. A September 2016 examination regarding the Veteran’s IBS noted that his ability to work was affected by daily diarrhea with the need for frequent breaks. A June 2018 VA examination which addressed the Veteran’s lumbar spine disability concluded that the Veteran’s ability to work was affected as the condition rendered him unable to stand, sit, or walk for extended periods. Likewise, a June 2018 examiner indicated that the Veteran’s left knee limited his ability to stand and walk. At the time of an April 2019 VA examination, the Veteran’s symptoms were noted as depressed mood, anxiety, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. The examiner concluded that the Veteran’s mental condition was manifested by 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. The Veteran submitted a medical opinion from Dr. M. B. in September 2020. Dr. M. B. indicated that given the Veteran’s mental and physical limitations, side effects of medications, as well as his past relevant work and educational background, the Veteran was unable to maintain substantially gainful employment as a result of his service-connected other specified depressive disorder, migraine headaches, irritable bowel syndrome, and right ankle sprain. Dr. M. B. noted that only the Veteran’s service-connected conditions were considered in reaching her conclusion. Dr. M. B. also noted that while working, the Veteran was having issues with his mental health and symptoms and side effects of medications. It was noted that the Veteran’s mental health symptoms, migraines, and pain were interfering with his focus, attention, and sleep. Dr. M. B. also noted that that this has been the case since the date of claim. Dr. M. B. added that the Veteran was further limited by his service-connected left knee and lumbar spine disabilities. The Veteran also submitted a March 2018 medical opinion and Disability Benefits Questionnaire from Dr. H. H., which was associated with the claims file in September 2020. Dr. H. H. likewise concluded that the Veteran’s service-connected disabilities prevented him from maintaining a substantially gainful occupation without accommodations. Pertinently, Dr. H. H. noted the Veteran’s symptoms of chronic sleep impairment, difficulty establishing and maintaining relationships, difficulty adapting to stressful circumstances including work, disturbances of motivation and mood, near-continuous panic and depression affecting his ability to function effectively, mild memory loss, impairment of short and long-term memory, impaired impulse control, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Dr. H. H. opined that the Veteran could not sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his depressive disorder. Dr. H. H. also noted that the Veteran’s symptom complex related back to his original date of claim. The Board finds that the preponderance of the evidence demonstrates that the Veteran’s service-connected disabilities preclude him from securing and following a substantially gainful occupation. The Board does note that no VA examination of record concluded that any service-connected disability by itself precludes the Veteran from securing and following a substantially gainful occupation. However, the Board notes the collective findings of the VA examinations of record; indicating that the Veteran’s left knee, IBS, lumbar spine, and headaches all cause functional impairment that limit his ability to engage in any activity for a prolonged period without frequent breaks. Additionally, the Board finds highly probative the opinion rendered by Dr. M. B., who concluded that the Veteran was unable to maintain substantially gainful employment; given his mental and physical limitations, work experience, and educational background. Likewise, the Board finds highly probative the opinion of Dr. H. H., who reached the same conclusion; noting that the Veteran could not sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his depressive disorder. Finally, the Board notes that VA is required to consider the Social Security Administration's (SSA) findings. However, the Board is not bound by the findings of disability and/or unemployability made by other agencies, including SSA. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991). Adjudication of VA and SSA claims are based on different laws and regulations. To that extent, while the Board acknowledges SSA’s finding that the Veteran could have engaged in other work, the Board assigns higher probative value to the medical evidence of record discussed above. The Board finds that given the Veteran’s physical limitations and impairment related to his depressive disorder, he would be unable to secure and follow substantially gainful employment in any work setting. Accordingly, the Veteran’s claim for a TDIU is granted. 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS FOR REMAND 1. Entitlement to service connection for bilateral hearing loss is remanded. When this matter was last before the Board in January 2019, it was remanded to obtain clinical findings from an August 9, 2016 VA audiological evaluation, as well as any clinical findings from any other VA audiological evaluation. Notably, the August 2016 treatment record indicated that the Veteran had moderate sensorineural hearing loss on the right and essentially within normal limits hearing on the left, with excellent speech discrimination for each ear. The Veteran’s VA treatment records further show a diagnosis of asymmetrical hearing loss. While development was undertaken to obtain any outstanding audiological evaluations, it does not appear that such findings were associated with the claims file. In this case, as there is evidence that the Veteran may have a hearing loss disability, evidence of in-service noise exposure, and given that the Veteran was awarded service connection for tinnitus based on such exposure, remand is warranted to afford the Veteran a contemporaneous VA examination and medical opinion. 2. Entitlement to service connection for a bilateral foot condition is remanded. The Veteran’s March 1989 entrance examination notes a diagnosis of mild bilateral asymptomatic pes planus. The Board also notes the Veteran’s complaint of foot pain during service in November 1992. Additionally, at the time of the Veteran’s December 1992 separation examination, he reported foot trouble. As pes planus was noted at service entrance, the Board finds that the presumption of soundness at entry into service does not attach. 38 U.S.C. § 1153. Likewise, as the Veteran's preexisting pes planus was noted at the time of entry into service, service connection for a bilateral foot condition may be granted only if it is shown that the condition worsened in severity beyond its natural progression during service, i.e., was "aggravated by" service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Accordingly, remand is warranted to obtain a medical opinion to address aggravation of the Veteran’s preexisting bilateral foot disability during active service. 3. Entitlement to service connection for a cervical spine disability is remanded. The Veteran contends that he suffers from a cervical spine disability that is related to active service. The Board notes that the Veteran’s service treatment records (STRs) show a complaint of cervical spine stiffness in August 1990 and treatment for a cervical strain in July and August 1992 following a motor vehicle accident. The Board further notes that an October 2019 VA treatment record shows a notation of osteoarthritis of the cervical spine. Further, the Veteran reported in a separate October 2019 entry that he was treated by a surgeon at Ochsner Medical center who recommended cervical surgery. Thus far, no examination or opinion has been provided on this issue. Accordingly, as the record indicates that the Veteran has a current diagnosis that may be associated with active service, a remand seeking such an examination and opinion is necessary. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 4. Entitlement to service connection for a right hip disability is remanded. 5. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a left hip disability is remanded. The Veteran contends that his bilateral hip disability is related to active service. The Veteran’s STRs indicate that he was shown to have a history of bilateral hip pain in April 1991. He was also treated for right hip pain in June 1992. Finally, at the time of his December 1992 separation examination, the examining physician noted a history of a right hip condition. The Veteran was afforded a VA examination in January 2014. He was noted to have a diagnosis of a bilateral hip sprain. The examiner noted the Veteran’s report of injuring his hips after a fall during service. The examiner rendered an opinion as to the Veteran’s right hip only; finding that condition was not related to service or any hip injury during service. As rationale, the examiner stated that the Veteran reported an acute hip injury during service that was treated conservatively and not immobilized for any length of time. The examiner also noted normal hip x-rays in January 2014. However, the examiner indicated that the Veteran’s STRs were not available for review at the time the opinion was rendered. Here, the Board notes the Veteran’s STRs were not associated with claims file until April 2015. As evidence related to the Veteran’s hip injury and notation of a right hip condition is undoubtedly relevant, and the January 2014 opinion was rendered without review of said evidence, the Board finds that remand is warranted for a contemporaneous medical opinion. 6. Entitlement to service connection for a right shoulder disability is remanded. The Veteran contends that his right shoulder disability is related to active service. The Veteran’s STRs indicate that he was treated for a right shoulder injury in March 1989. While the Veteran did not report a history of a right shoulder condition during his entrance examination, at the time of the March 1989 injury he reported that he had previously injured the shoulder 4 years prior. The Veteran was afforded a VA examination in January 2014. The Veteran was noted to have a diagnosis of a right shoulder sprain. The examiner noted the Veteran’s report of injuring his right shoulder after falling during service. The examiner opined that the Veteran’s current right shoulder condition was not related to service or any right shoulder injury during service. As rationale, the examiner stated that x-ray findings did not show any significant anatomical changes due to trauma or excessive activity. However, the examiner indicated that the Veteran’s STRs were not available for review at the time the opinion was rendered. Here, the Board again notes the Veteran’s STRs were not associated with claims file until April 2015. As evidence related to the Veteran’s right shoulder injury is undoubtedly relevant and the January 2014 opinion was rendered without review of said evidence, the Board finds that remand is warranted for a contemporaneous medical opinion. Additionally, the Board notes that the Veteran’s reports of a right shoulder injury 4 years prior to service raises the possibility that the he may have had a preexisting right shoulder disability. The Board notes that a veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1132. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). Accordingly, the opinion rendered should address whether the Veteran clearly and unmistakably had a right shoulder disability that preexisted active service, and if so, whether the condition was clearly and unmistakably not aggravated during service. 7. Entitlement to service connection for costochondritis and dehydration, claimed as chest pains is remanded. 8. Entitlement to service connection for shaking spells is remanded. 9. Entitlement to service connection for fibromyalgia, to include as due to an undiagnosed illness is remanded. 10. Entitlement to service connection for a sleep disorder, claimed as chronic fatigue syndrome, to include as due to an undiagnosed illness is remanded. 11. Entitlement to service connection for unspecified joint pain, to include as due to an undiagnosed illness is remanded. 12. Whether new and material evidence has been received to reopen a previously denied claim for service connection for body aches and pains, to include as due to an undiagnosed illness is remanded. 13. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a left shoulder disability is remanded. The Veteran seeks service connection for fibromyalgia, shaking spells, costochondritis and dehydration, chronic fatigue syndrome, and unspecified joint pain, to include as an undiagnosed illness or a medically unexplained chronic multi-symptom illness. The Veteran also seeks service connection for several musculoskeletal disabilities to include cervical spine, left ankle, bilateral hip, and bilateral shoulder. Service connection may be granted for claims related to service during the Persian Gulf War may if there is (1) an undiagnosed illness, and (2) evidence of a chronic disability. Gutierrez v. Principi, 19 Vet. App. 1 (2004). The chronic disability must not be attributed to any known clinical diagnosis and must result from an illness or combination of illnesses manifested by one or more signs and symptoms that (1) became manifest during active service in the Southwest Asia theater of operations during the Persian Gulf War, or (2) manifested to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1)(i)-(ii). Qualifying chronic disabilities include medically unexplained chronic multi-symptom illnesses-such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome-that are defined by a cluster of signs or symptoms. 38 U.S.C. § 1117(a). Signs and symptoms include: (1) fatigue; (2) unexplained rashes or other dermatological signs or symptoms; (3) headache; (4) muscle pain; (5) joint pain; (6) neurological signs or symptoms; (7) neuropsychological signs or symptoms; (8) upper or lower respiratory system signs or symptoms; (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 U.S.C. § 1117(g). In this case, the Veteran was afforded a VA Gulf War examination in January 2014. At the time, the examiner indicated that the Veteran had diagnoses of fibromyalgia and chronic fatigue syndrome; noting that the conditions were diagnosable, but medically unexplained. The Veteran’s fibromyalgia was found to result in symptoms of widespread musculoskeletal pain, stiffness, muscle weakness, and sleep disturbance. The Veteran’s tender points for pain were noted as “all bilaterally”. The examiner also concluded that the Veteran had joint pain, which was a diagnosable chronic multi-symptom illness with a partially explained etiology. The examiner further concluded that the Veteran’s joint pain was not related to active service. Here, the Board notes that while the Veteran’s widespread musculoskeletal pain, stiffness, and muscle weakness has been attributed to fibromyalgia, the medical evidence of record also shows various diagnoses to include primary osteoarthritis involving multiple joints, bilateral hip strain, and a right shoulder sprain. Additionally, while the Veteran has a sleep disturbance that has been attributed to fibromyalgia and he was also found to have chronic fatigue syndrome, the medical evidence of record also shows a current diagnosis of sleep apnea. Given the conflicting medical evidence, which both attributes the Veteran’s claimed disabilities to a medically-unexplained illness as well as to diagnosed conditions, the Board finds that remand is warranted to obtain a new VA examination to reconcile the evidence of record. 14. Entitlement to a rating in excess of 10 percent for a right ankle disability is remanded. Remand is necessary in light of Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016), which held that an adequate VA examination of the joints must, wherever possible, include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing, and with range-of-motion measurements of the opposite undamaged joint. The Veteran was last afforded a VA examination in September 2016. The examination report does not indicate that such testing was conducted. Accordingly, the Veteran should be afforded a new VA examination. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed hearing disability. The examiner is asked to respond to the following: a.) Determine whether the Veteran has a hearing loss disability for VA purposes in either ear. b.) For any diagnosed hearing loss disability, opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s hearing loss had its onset in, or is otherwise related to, active military service. The examiner must address the May 2014 VA examination, noting that the Veteran was routinely exposed to hazardous noise and finding that his diagnosed tinnitus was related to such exposure. 2. Schedule the Veteran for a VA examination to determine the nature and severity of his preexisting bilateral foot disability. The examiner is asked to respond to the following: a.) Whether there is clear and unmistakable evidence that the Veteran’s bilateral pes planus was not aggravated beyond its natural progression during active service. The examiner must address the Veteran’s complaint of foot pain in November 1992 and report of foot trouble at the time of his December 1992 separation examination. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed cervical spine disability. The examiner is asked to respond to the following: a.) Determine whether the Veteran has a current diagnosis of a cervical spine disability. b.) Whether it is at least as likely as not (50 percent or greater probability) that any current cervical spine disability had its onset in service or is otherwise etiologically related to active service. The examiner must address the Veteran’s service treatment records (STRs) showing a complaint of cervical spine stiffness in August 1990 and treatment for a cervical strain in July and August 1992 following a motor vehicle accident. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed right shoulder disability. The examiner is asked to respond to the following: a.) Is there clear and unmistakable (obvious or manifest, undebatable) medical evidence to demonstrate that a right shoulder disability existed prior to the Veteran's entrance into service? b.) If a right shoulder disability clearly and unmistakably preexisted the Veteran's active service, is there clear and unmistakable evidence that the disability was not aggravated beyond its natural progression during active service? c.) If a right shoulder disability is not found to have clearly and unmistakably preexisted service, is it at least as likely as not (50 percent or greater probability) that any current right shoulder disability had its onset in service or is otherwise etiologically related to active service? Attention is invited to the Veteran’s STRs showing a March 1989 right shoulder injury and his reports of injuring the shoulder 4 years prior. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed hip disability. The examiner is asked to respond to the following: a.) Whether it is at least as likely as not (50 percent or greater probability) that any current bilateral hip disability had its onset in service or is otherwise etiologically related to active service? Attention is invited to the Veteran’s STRs noting a history of bilateral hip pain in April 1991; treatment for right hip pain in June 1992; and a December 1992 separation examination, noting a history of a right hip condition. 6. Schedule the Veteran for a Gulf War examination. The claims file, including a copy of this remand, must be made available to and reviewed by the examiner. The VA examiner should conduct all necessary testing to rule out a diagnosis for the claimed signs and symptoms: musculoskeletal and joint pain (cervical spine, left ankle, bilateral hip, and bilateral shoulder), fibromyalgia, chronic fatigue syndrome, sleep disorder, chest pains, costochondritis and dehydration, and shaking spells. The examiner is asked to respond to the following: a.) The examiner should characterize the Veteran's claimed disabilities as belonging to one of four disability patterns: (1) undiagnosed illness, (2) a diagnosable, but medically unexplained chronic multisymptom illness of unknown etiology, (3) a diagnosable chronic, multisymptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology. The examiner should specifically address symptoms related to the Veteran’s cervical spine, left ankle, bilateral hips, and bilateral shoulders. The examiner should also address any evidence of record showing a sleep disorder, to include sleep apnea. b.) If any condition is attributable to a disorder other than chronic fatigue syndrome or fibromyalgia, the examiner should state an opinion as to whether is it at least as likely as not (50 percent or greater probability) that the diagnosed disorder began in service, was caused by service, or is otherwise related to the Veteran's active service, to include the Veteran's service and chemical exposure in the Persian Gulf. The examiner must provide a complete rationale for all opinions expressed. As part of this rationale, the examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). A discussion of the facts and medical principles involved would be of considerable assistance to the Board. 7. Schedule the Veteran for an examination to determine the nature and severity of his service-connected right ankle disability. The examiner should review pertinent documents in the Veteran's claims file and this Remand in connection with the examination. All indicated studies should be completed, and all pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. a.) The examiner should conduct range of motion studies and assess any functional impairment due to such factors as pain and weakness, and express this functional impairment in terms of further loss of motion. b.) The examiner should test the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. c.) Obtain from the Veteran a complete history of any flare-ups of the right ankle disability. In so doing, the examiner should inquire as to the frequency, duration, characteristics, severity, and functional loss during periods of flare-ups of the disability. The examiner should describe the additional loss, to include in degrees, if possible or sufficiently explain why any additional functional loss cannot be described or quantified. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Marsh II, Associate 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.