Citation Nr: 21032255 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 14-18 230 DATE: May 26, 2021 ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for a sleep disability. 3. Entitlement to an increased disability evaluation in excess of 10 percent for hemorrhoids. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). 5. Entitlement to a compensable disability evaluation for vascular headaches, migraine type. 6. Entitlement to an increased disability evaluation in excess of 10 percent for gastroesophageal reflux disease (GERD). 7. Entitlement to service connection for a disability manifested by chronic itching to the head and scalp. 8. Entitlement to service connection for a disability manifested by anxiety, variously claimed as panic attacks, bipolar disorder, and post-traumatic stress disorder (PTSD). 9. Entitlement to service connection for a disability manifested by depression, variously claimed as secondary to degenerative arthritis of the thoracolumbar spine and degenerative disc disease of the cervical spine. 10. Entitlement to service connection for varicose veins. 11. Entitlement to service connection for a left ankle disability. 12. Entitlement to service connection for a right ankle disability. 13. Entitlement to service connection for a left knee disability. 14. Entitlement to service connection for a right knee disability. 15. Entitlement to service connection for a left lower extremity shin disability. 16. Entitlement to service connection for a right lower extremity shin disability. ORDER The appeal on the issue of entitlement to service connection for hypertension has been withdrawn. The appeal on the issue of entitlement to service connection for a sleep disability has been withdrawn. The appeal on the issue of entitlement to an increased disability evaluation in excess of 10 percent for hemorrhoids has been withdrawn. The appeal on the issue of entitlement to a TDIU has been withdrawn. Entitlement to a disability evaluation for vascular headaches, migraine type, of 30 percent prior to April 25, 2017, and 10 percent thereafter, but no higher, is granted. Entitlement to an increased disability evaluation of 30 percent, but no higher, for gastroesophageal reflux disease (GERD) is granted. REMANDED Entitlement to service connection for a disability manifested by chronic itching to the head and scalp is remanded. Entitlement to service connection for a disability manifested by anxiety, variously claimed as panic attacks, bipolar disorder, and post-traumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a disability manifested by depression, variously claimed as secondary to degenerative arthritis of the thoracolumbar spine and degenerative disc disease of the cervical spine, is remanded. Entitlement to service connection for varicose veins is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left lower extremity shin disability is remanded. Entitlement to service connection for a right lower extremity shin disability is remanded. FINDINGS OF FACT 1. At the March 2021 hearing, the Veteran through his attorney informed the Board that he wished to withdraw his appeal related to entitlement to service connection for hypertension. 2. At the March 2021 hearing, the Veteran through his attorney informed the Board that he wished to withdraw his appeal related to entitlement to service connection for a sleep disability. 3. At the March 2021 hearing, the Veteran through his attorney informed the Board that he wished to withdraw his appeal related to entitlement to an increased disability evaluation in excess of 10 percent for hemorrhoids. 4. At the March 2021 hearing, the Veteran through his attorney informed the Board that he wished to withdraw his appeal related to entitlement to a TDIU. 5. Prior to April 25, 2017, vascular headaches, migraine type were manifested by daily pulsating or throbbing head pain on the right side of the head, causing the Veteran to lay down four to five times per month, with sensitivity to light, and occasional drooping in the left eye. 6. From April 25, 2017, vascular headaches, migraine type were manifested by pulsating or throbbing head pain on both sides of the head lasting less than one day, with nausea, sensitivity to light and sound, changes in vision, and with prostrating attacks over the last several months occurring less frequently than once in two months. 7. Gastroesophageal reflux disease (GERD) has been manifested by recurrent epigastric distress with heartburn, burping, chest pain, diminished dysphasia, and regurgitation, productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal by the Veteran on the issue of entitlement to service connection for hypertension have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for withdrawal of a substantive appeal by the Veteran on the issue of entitlement to service connection for a sleep disability have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for withdrawal of a substantive appeal by the Veteran on the issue of entitlement to an increased disability evaluation in excess of 10 percent for hemorrhoids have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 4. The criteria for withdrawal of a substantive appeal by the Veteran on the issue of entitlement to a total disability rating based on individual unemployability (TDIU) by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 5. Prior to April 25, 2017, the criteria for a disability evaluation of 30 percent, but no higher, for vascular headaches, migraine type have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.3.21, 4.1, 4.14, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8100 (2018). 6. From April 25, 2017, the criteria for a disability evaluation of 10 percent, but no higher, for vascular headaches, migraine type have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.3.21, 4.1, 4.14, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8100 (2018). 7. The criteria for an increased disability evaluation of 30 percent, but no higher, for gastroesophageal reflux disease (GERD) have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.114, 4.14, 4.3, 4.7, Diagnostic Code 7346 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1978 to June 1998. This matter is before the Board of Veterans Appeals (Board) on appeal from June 2013, October 2016, and July 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran testified before the undersigned Veterans Law Judge (VLJ) in March 2021. A copy of the hearing transcript has been associated with the claims file. The Board observes that a recent March 2021 Rating decision granted service connection for erectile dysfunction and special monthly compensation (SMC) based on loss of use. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). At the March 2021 hearing, the Veteran through his attorney requested several Compensation & Pension examinations. This is addressed in the Remand section below. The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Withdrawn Appeals 1. Entitlement to service connection for hypertension 2. Entitlement to service connection for a sleep disability 3. Entitlement to an increased disability evaluation in excess of 10 percent for hemorrhoids 4. Entitlement to a total disability rating based on individual unemployability (TDIU) The Board incorporates its discussion from the sections above by reference. Only an appellant, or an appellant's authorized representative, may withdraw an appeal. An appeal may be withdrawn as to any or all issues involved in the appeal. 38 C.F.R. § 19.55 (a). Appeal withdrawals must include the name of the veteran, the name of the claimant or appellant if other than the veteran (e.g., a veteran's survivor, a guardian, or a fiduciary appointed to receive VA benefits on an individual's behalf), the applicable Department of Veterans Affairs file number, and a statement that the appeal is withdrawn. If the appeal involves multiple issues, the withdrawal must specify that the appeal is withdrawn in its entirety, or list the issue(s) withdrawn from the appeal. 38 C.F.R. § 19.55 (b)(1). Withdrawal of an appeal will be deemed a withdrawal of the Notice of Disagreement and, if filed, the Substantive Appeal, as to all issues to which the withdrawal applies. Withdrawal does not preclude filing a new Notice of Disagreement and, after a Statement of the Case is issued, a new Substantive Appeal, as to any issue withdrawn, provided such filings would be timely under these rules if the appeal withdrawn had never been filed. 38 C.F.R. § 19.55 (c). The Board may dismiss any appeal which fails to identify the specific determination with which the claimant disagrees. 38 U.S.C. § 7105 (d). By way of history, at the March 2021 hearing, the Veteran through his attorney informed the Board that he wished to withdraw his appeals related to entitlement to service connection for hypertension, service connection for a sleep disability, an increased disability evaluation in excess of 10 percent for hemorrhoids, and a total disability rating based on individual unemployability (TDIU). The Veteran's attorney confirmed, "We will be withdrawing at this time the issue of entitlement to a rating in excess of 10 percent for hemorrhoids. We will be withdrawing the issue of entitlement to service connection for hypertension. We will be withdrawing the issue of entitlement to service connection for obstructive sleep apnea. And we have previously, but just to reiterate on the record, withdrawn the issue of entitlement to a total disability rating based on individual unemployability." See March 2021 hearing transcript, p. 3. The VLJ later accepted withdrawal of these issues. Accordingly, the Board does not have jurisdiction to review these issues on appeal. Therefore, these issues on appeal are dismissed. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability ratings have not been previously staged. As discussed below, a uniform evaluation is still warranted for GERD, but a staged rating is now warranted for vascular headaches. 5. Entitlement to a compensable disability evaluation for vascular headaches, migraine type The Board incorporates its discussion from the sections above by reference. The Veteran's vascular headache disability is assessed as having a noncompensable disability rating under DC 8100. 38 C.F.R. § 4.124a. He asserts that the current rating does not accurately reflect the degree of severity of the disability. By way of rating criteria, DC 8100 provides ratings for migraine headaches. Migraine headaches with less frequent attacks than the criteria for a 10 percent rating are rated as noncompensable (0 percent disability rating). Migraine headaches with characteristic prostrating attacks averaging one in two months over the last several months are rated 10 percent disabling. Migraine headaches with characteristic prostrating attacks occurring on an average once a month over last several months are rated 30 percent disabling. Migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability are rated 50 percent disabling. 38 C.F.R. § 4.124a, DC 8100. By way of background, the Veteran was afforded a March 2017 VA headaches examination with Disability Benefits Questionnaire (DBQ). The VA examiner found in part, "The Headaches occur daily which last one-five minutes and occur three times a day. He states that if he has a second headache while at work in a day he goes home, but then works at home. Since onset his condition has slightly improved." Headaches were on the right side of the head. He had sensitivity to light, and his left eye occasionally dropped. There were no characteristic prostrating attacks. Next, the Veteran was afforded a January 2018 VA headaches examination. the Veteran described daily headaches that he treats with medication. Symptoms included pulsating or throbbing head pain, pain on both sides of the head, pain worsening with physical activity, nausea, and sensitivity to light and sound. The duration of typical head pain was less than one day on both sides of the head. Characteristic prostrating attacks were "with less frequent attacks," meaning one level less than once in 2 months. Importantly, at the March 2021 hearing, the Veteran testified regarding the history and severity of his headache disability. He clarified the frequency of debilitating headaches. He recounted: Well, the headaches would come on as sharp pain all through my front and back side of the brain. I don't know what would cause the headaches, but they got so strong and powerful that I would have to drop whatever I was doing, and that would occur around maybe four or five times a month. And for a few minutes, from five to ten minutes, I'd have to lay down. And during that time, I would wait for the headache to pass. The best thing I would do then is take a baby aspirin, and that would, according to my cardiologist, would assist me with any --alleviate the pain. So I did see a neurologist regarding those headaches, and I did see -- but he referred me to a cervical -- a surgeon. He referred to me a surgeon, and the surgeon did see me. The neurologist said that he could not ascertain specifically, but that he attributed the radiculopathy to maybe. That was just a medical opinion on him, and I did see the surgeon. And I don't know if you want me to go into what happened there or you just want me to limit to the (emphasis added). See March 2021 hearing transcript, p. 8. The Veteran continued describing a lessening in the severity of migraine headaches because of surgery he received for the cervical spine. Well, after that, I did go -- I did see the specialist --the surgeon. He conducted several exams, and he took the x-rays of my upper and lower spine, and he concluded that what was happening was that my vertebrae, my 5,6, and 7 vertebrae was -- had been damaged. And of course, he couldn't ascertain from where, but that he concluded that I would needed spinal surgery, spinal fusion, ACDF surgery. And he told me The Veteran described surgery on April 25, 2017 that included a three day stay at the hospital. Id. at pp. 8-9. The Veteran and his attorney went on to testify that prior to surgery in 2017, the Veteran had periods during which he could not do anything and had to take time off work. After the symptomology improved following surgery in 2017, he was able to work through a lot of headaches and continue to still work after 2017. Id. at p. 10. The VLJ clarified, "You would have --these headaches would cause you to lay down four to five times per month, and generally that's what you experienced from about 2011 until 2017, Mr. [Veteran]?" Id. at p. 11. The Veteran responded in the affirmative. The Veteran described that since 2017, headaches causing him to lay down occurred three or four times per month and not as frequent. The Veteran through his attorney requested a staged rating and a 30 percent disability rating prior to 2017 at a minimum. Additional VA and private treatment records are substantially the same. The Veteran contends that he is entitled to a compensable disability evaluation of at least 30 percent prior to April 25, 2017 and a compensable evaluation thereafter for vascular headaches. Vascular headaches are currently rated as zero percent disabling based upon migraine headaches occurring daily lasting one to five minutes, three times per day, with less frequent attacks and slight improvement in the condition. A higher, compensable evaluation of 10 percent is not warranted for migraine headaches unless the evidence shows headaches with characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent disability evaluation contemplates even more frequent and severe impairment. Such is the case here, as the most probative evidence demonstrates at least such frequent and severe impairment. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). He is competent to report having to lay down four to five times per month prior to April 2017, and that he experienced this from 2011 until April 2017. He is competent to report the frequency of such events, and that they have been somewhat relieved by medication and cervical spine surgery. We have considered his credible lay reports. Here, the most probative evidence is the clinical findings of the VA examiners and the Veteran's lay hearing testimony. The VA examiners reviewed the entire claims file, considered the Veteran's lay history, and performed a complete physical examination. The Board observes that the March 2017 VA examination still shows that although the Veteran would go home during a headache episode, he could work at home. We assign substantial probative weight to these findings. In addition, the Veteran competently and credibly reported his lay history of headaches causing impairment. He reported a change in the symptoms following cervical spine surgery on April 25, 2017. Relatively consistent with the VA examination results, he reported prior to surgery that he had to sit down or go home when he experienced a headache. Headaches caused him to lay down four to five times per month prior to surgery, but not as frequently after surgery in 2017. We assign substantial probative weight to his lay hearing testimony. First, we consider the stage prior to April 25, 2017. This is the date when the Veteran reported surgery and a lessoning of his symptoms. Prior to April 25, 2017, the Veteran's symptoms most closely approximate the criteria at the 30 percent disability level. The Veteran's symptoms involve pulsating or throbbing head pain on the right side of the head, causing him to have to lay down four to five times per month. His hearing testimony establishes that he would have to lay down for five to ten minutes. He also had sensitivity to light, with occasional drooping in the left eye. This impairment is best summarized by the criteria for a 30 percent disability evaluation. An even higher rating disability evaluation would require very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The record does not indicate that the Veteran experienced very frequent completely prostrating and prolonged attacks. While the Veteran is competent to report his experiences, and reports that at times he had to take some time off work, the record does not support an interpretation that these attacks are completely prostrating. It shows relatively brief rather than prolonged attacks. Therefore, a disability evaluation for vascular headaches, migraine type, of 30 percent, but no higher, is warranted. Turning to the stage from April 25, 2017, this was the date when there was evidence of a change. The preponderance of the evidence demonstrates an improvement in the severity of headache impairment after the Veteran underwent serious cervical spine surgery. He testified, "Yes, they lessened, but they did not completely leave. I do not know if the remaining headaches are part of the operation itself --the surgical operation itself because it was invasive." See March 2021 hearing transcript, p. 9. At the March 2018 VA examination, the VA examiner found migraines were manifested by pulsating or throbbing head pain on both sides of the head, with nausea, sensitivity to light and sound, and changes in vision, lasting less than one day, and with prostrating attacks over the last several months occurring less frequently than once in two months. We have assigned the most probative weight to the lay evidence and these clinical findings of the VA examiner. It suggests some improvement. Therefore, the severity of migraines most closely approximates an increased, 10 percent disability evaluation from April 25, 2017. An even higher disability evaluation is not warranted because the impairment was not of more serious frequency or severity. The weight of the evidence does not establish characteristic prostrating attacks occurring on an average once a month over last several months. The Veteran's attorney asserted that the Veteran could still continue to work through his headaches after 2017. See March 2021 hearing transcript, p. 10. He had to lay down less frequently. Therefore, from April 25, 2017, a disability evaluation for vascular headaches, migraine type, of 10 percent, but no higher, is warranted. In reaching these favorable outcomes, we note that these are consistent with the ratings requested by the Veteran's attorney at the March 2021 hearing. This represents a complete grant of the specific benefit sought on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). We note that symptoms may wax and wane across the staged appeals periods. There is no doubt to resolve. Therefore, entitlement to a disability evaluation for vascular headaches, migraine type, of 30 percent prior to April 25, 2017, and 10 percent thereafter, but no higher, is warranted. 6. Entitlement to an increased disability evaluation in excess of 10 percent for gastroesophageal reflux disease (GERD) The Board incorporates its discussion from the sections above by reference. GERD is currently rated as 10 percent disabling under Diagnostic Code (DC) 7346, which pertains to the digestive system. 38 C.F.R. § 4.114. (2018). DC 7346 is for hiatal hernia. Under DC 7346, an evaluation of 10 percent is warranted for two or more of the symptoms for the 30 percent evaluation of less severity. An evaluation of 30 percent is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. By way of background, the Veteran was afforded an October 2011 VA examination encompassing several conditions. For GERD, he reported dysphagia, heartburn, epigastric pain, scapular pain, arm pain, and regurgitation. Every symptom but vomiting was a daily problem. He had scapular pain and arm pain. Later, VA treatment records show impressions of and treatment for GERD. An October 16, 2015 VA General Surgery Note is of record. It reads: Chief Complaint / History of Present Illness: 63yo M who presents for evaluation for significant GERD. His symptoms include daily epigastric pain, secretions, dysphagia, cough, and possible aspiration symptoms. He has been worked up at outside facilities with EGD (question of dysplasia?), mammometry (sic), and pH probe studies; he is unsure of the results of any of these studies. He was previously not taking his PPI properly, but now states he takes it properly, however is still experiencing symptoms and remains interested in surgery. Next, the Veteran was afforded a March 2017 VA esophageal conditions examination with Disability Benefits Questionnaire (DBQ). The VA examiner identified the disease entity. The Veteran reported that he developed GERD in 1985 and that the condition has remained unchanged since its onset. He took related medication. The VA examiner identified several symptoms of GERD. They were dysphagia, pyrosis (heartburn), reflux, and regurgitation. There was no substernal, arm or shoulder pain. On June 11, 2019, VA received additional private treatment records from Memorial Hermann Surgical Hospital First Colony and rR. G. P. D. L., M.D. They show that the Veteran had an operation related to GERD and hiatal hernia on November 29, 2018. The operation performed was laparoscopic Nissen fundoplication. There were no complications. Next, the Veteran testified in March 2021 regarding the severity of GERD. The Veteran through his attorney explained that in 2015 he was suffering from gastritis pain in his chest. He went to the emergency room. He was given an EKG but the ultimate determination was that he was having gaseous pain and stomach issues. The Veteran described: I've been suffering from that since I can remember. I mean since I was in active duty with esophageal, (inaudible). I was diagnosed with that, but back in -- since I can remember back since 1985 on and off, but it just worsened after -- through the duration of time, it just got worse and worse where I constantly had acid reflux and pain chest and dysphasia -- esophageal dysphasia, and I had to see a specialist. A gastro specialist here in Houston who then recommended in his final declaration I had the upper --where they put the tube in and the colonoscopy and endoscopy, and he concluded that I needed a fundoplication operation because my esophageal was already worn out. And I had a hiatal hernia, which is part of the VA medical records. You will find all of that there. So in all, it's been since I can remember back in 1985 and during the time frame of active duty until I left in 1998. And then after 1998, it continued. It's just gotten --escalation of being a worse medical condition. See March 2021 hearing transcript, pp. 13-14. The Veteran testified that he saw a gastro doctor 15 years ago, but in 2012 he had surgery. He still has heartburn, burping, chest pain, diminished dysphasia, and regurgitation. Id. at pp. 15-16. Ongoing VA and private treatment records are substantially the same. The Veteran contends that he is entitled to an increased disability evaluation for GERD. The current rating contemplates dysphagia, pyrosis, and regurgitation. A higher evaluation is not warranted unless there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The most probative evidence demonstrates that a 30 percent disability evaluation best contemplates the Veteran's cluster of symptoms. The Veteran competently testified that he has had GERD for several years. He still experiences heartburn, burping, chest pain, diminished dysphasia, and regurgitation. He competently reported that treatment providers in 2015 attributed an episode of chest pain to GERD. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). These credible reports are consistent with the VA and private treatment records. The most probative evidence is the March 2017 VA examination results and the Veteran's lay hearing testimony. First, the March 2017 VA examination confirmed the long history of impairment. It showed symptoms of dysphagia, pyrosis (heartburn), reflux, and regurgitation. We assign substantial probative weight to these findings. The Board also assigns the most probative weight to the Veteran's March 2021 hearing testimony. He recounted being hospitalized in 2015 for what was ultimately determined to be pain attributable to GERD. He described that he has experienced impairment, "since I can remember back since 1985 on and off, but it just worsened after -- through the duration of time, it just got worse and worse where I constantly had acid reflux and pain chest and dysphasia -- esophageal dysphasia, and I had to see a specialist." See March 2021 hearing transcript, p. 13. He still has heartburn, burping, chest pain, diminished dysphasia, and regurgitation. Id. at pp. 15-16. Here, the evidence suggests that throughout the appeals period, a higher, 30 percent disability evaluation for GERD most closely summarizes the Veteran's impairment. This is based upon persistently recurrent epigastric distress with heartburn, burping, chest pain, diminished dysphasia, and regurgitation, productive of considerable impairment of health. The VA examination results and the Veteran's competent testimony regarding his symptoms establishes these facts. We note that burping and chest pain are capable of lay observation. The Veteran has sought treatment and reported considerable impairment of his health. Turning to the next higher rating, the most probative evidence also does not show that his symptoms have consistently been accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. He has changed his diet and lost weight, which has helped to not experience quite as severe symptoms. The Veteran's symptoms are not of the frequency or severity to warrant the next higher rating. In reaching this favorable decision, we note that this increased rating is within the bounds requested by the Veteran's attorney at the March 2021 hearing. This represents a complete grant of the specific benefit sought on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). There is no doubt to resolve. Accordingly, an increased disability evaluation of 30 percent, but no higher, for gastroesophageal reflux disease (GERD) is warranted. In reaching these conclusions, the Board has favorably applied the benefit of the doubt rule. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board generally observes that the Veteran is currently in receipt of a 100 percent schedular rating. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND In light of the Veteran and his attorney's contentions, a remand is necessary to ensure that the Veteran is afforded due process, and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. To establish service connection a Veteran must generally show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). The Veteran through his attorney testified at the March 2021 hearing. The duty to assist requires that a medical examination be provided when it is "necessary to make a decision on the claim." 38 U.S.C. § 5103A(d)(1). And, in Miller v. Wilkie, 32 Vet. App. 249 (2020), the United States Court of Appeals for Veterans Claims (Court) recently held that this duty required that an examiner "address the veteran's lay statements to provide the Board with an adequate medical opinion," in part because "medical opinions can inform credibility findings." On remand, as it is developing the record, the Board is mindful of Miller and the duty to assist. 1. Entitlement to service connection for a disability manifested by chronic itching to the head and scalp is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the Veteran testified in March 2021 regarding his claimed scalp disability. He explained: I'm receiving a gel specifically from the Veterans Administration VA doctor that I'm seeing, my primary care manager. And that gel is supposed to assist me with a possible scalp condition. But he -- dermatologists, private and VA doctors, have not ascertained something wrong with the scalp per se. Eczema -- the have found eczema in the past, and they have found, of course, dandruff and that, but they took a biopsy of the scalp and could not ascertain where the itch would come from, whether it was psychological, whether it was anxiety, whether it was-- the biopsy did not reveal any medical term. There was no -- but he -- the gel has helped me. They send the gel at least once every two months. See March 2021 hearing transcript, p. 27. The Veteran described that during service he just had a constant itch but he did not know what it was from. It began around 1980 while he was stationed near Frankfurt, Germany at MIESAU Army Depot. Id. at pp. 27-30. His scalp still constantly itches. The Veteran's attorney highlighted the continuous symptoms since service and the duty to assist in affording the Veteran a Compensation & Pension examination. Indeed, VA must provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). To fully address the Veteran's contentions, and to assist in fully developing the Veteran's claim, a VA examination with medical opinion for the claimed scalp disability is necessary. 2. Entitlement to service connection for a disability manifested by anxiety, variously claimed as panic attacks, bipolar disorder, and post-traumatic stress disorder (PTSD), is remanded. 3. Entitlement to service connection for a disability manifested by depression, variously claimed as secondary to service-connected degenerative arthritis of the thoracolumbar spine and degenerative disc disease of the cervical spine is remanded. The Board incorporates its discussion from the sections above by reference. As a threshold matter, the Board observes that these two issues are being considered under distinct diagnostic codes DC 9432 for bipolar disorder, including as a psychosis and with neuropsychological signs and symptoms associated with anxiety, and DC 9434 for depression. See March 26, 2021 Rating Decision Codesheet. They were adjudicated in separate rating decisions by the RO, and this was confirmed by the VLJ at the March 2021 hearing. See March 2021 hearing transcript, p. 3. The Board observes that there are service connection claims for a possible psychosis and for depression, which could be organic disease of the nervous system. Additional presumptive theories of entitlement are potentially relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). We will continue with this comprehensive approach to afford the Veteran the maximum possible benefit. Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310 (b). By way of history, on March 8, 2017, VA received a VA medical opinion from Dr. R. S., M.D. dated June 23, 2016. It shows that the Veteran has been with the general mental health clinic since 2011. He has a history of bipolar disorder with significant impairment in functioning in different settings, and anxiety attacks. Dr. R. S. suggested reduced driving distance to campus to improve his level of functioning due to anxiety attacks. Additional private treatment records received in a set on March 8, 2017 show a prior medical history of depression. Also on March 8, 2017, the Veteran submitted an addendum (Brief) regarding his psychiatric claims. He reports a history of depression, manic depression with bipolar VA medical diagnosis, and anxiety attacks. He describes his medical history, and attached a selection of private and VA treatment records. A separate statement submitted on March 8, 2017 describes impairment due to back and neck pain. It shows that this has caused depression. The Board has construed this as a secondary service connection claim. 38 C.F.R. § 3.310. Next, on October 19, 2018, VA received a private medical opinion from Dr. J. P. dated October 8, 2018. It is based upon the Veteran's reports. In the Analysis section, Dr. J. P. concludes that the Veteran meets the criteria for Unspecified Bipolar Disorder "which was acquire during his time in service." On the following page, the "Medical Nexus Opinion" section shows a positive nexus statement only for bipolar disorder. Nevertheless, there is not a rationale that immediately follows based upon a review of the record. At the March 2021 hearing, the Veteran's attorney explained: Our office has already provided an independent medical opinion. That independent medical opinion was dated October 8 of 2018 from a Dr. [J.] [P.] (phonetic). Dr. [P.] did provide a positive nexus opinion linking Mr. [Veteran's] psychological condition specifically identified by her -- excuse me as I'm looking to verify the diagnosis -- of unspecified bipolar disorder to military service specifically, and the nexus opinion also included a full review of the evidence of record, including the Veteran's claims file and previous Compensation & Pension examinations provided. The Veteran and his attorney did not provide additional testimony in light of this medical opinion. See March 2021 hearing transcript pp. 6-7. For these issues, there is not a complete medical opinion for all claimed conditions and based upon a full review of the record upon which a decision can be made. The October 2018 private medical opinion shows only a diagnosis of bipolar disorder, and a positive nexus. Second, the Veteran has reported variously diagnosed psychiatric impairment, coded by VA as ranging from DC 9432 for bipolar disorder to DC 9434 for depression. Third, he has submitted statements attributing depression to neck and lumbar spine pain, presenting an additional secondary service connection theory of entitlement. To fully address the Veteran's contentions, a remand is necessary for a VA examination with medical nexus opinions regarding the onset and etiology of the claimed disabilities. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 4. Entitlement to service connection for varicose veins is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the Veteran testified at the March 2021 hearing regarding varicose veins in his legs. They are painful when he walks, stands up, and massages them excessively. The Veteran asserted that they are attributable to, "longevity of service, of walking, of running." See March 2021 hearing transcript, p. 43. The Veteran reported that he had the same issue of raised, discolored, and painful veins in the military. Id. at p. 44. The Veteran's attorney concluded in part: However, if you disagree that Mr. [Veteran's] testimony is sufficient in order to grant entitlement, again we would be requesting a remand for a Compensation & Pension examination to identify any potential relationship between military service and his current issues regarding his varicose veins, just like with the remaining issues we've discussed, as to the ankles, the knees, and the shin splints, no C&P examination was provided to Mr. [Veteran] in the first instance of this case, Your Honor. Id. at pp. 48-49. For this issue, the Board observes that the Veteran is competent to report popping out and discolored veins since service. Nevertheless, in contrast to the Veteran's testimony, VA problem lists do not continuously include varicose veins. For example, July 17, 2019 CAPRI records contain a Problem List. It does not show varicose veins. Any references in prior VA treatment records are many years removed from separation based upon the dates of the records themselves. Still, his lay statements suggest possible continuity of symptomatology capable of lay observation, even without active treatment. To fully address the Veteran's contentions, and to assist in fully developing the Veteran's claim, a VA examination with medical opinion for varicose veins is necessary. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Entitlement to service connection for a left ankle disability is remanded. 6. Entitlement to service connection for a right ankle disability is remanded. 7. Entitlement to service connection for a left knee disability is remanded. 8. Entitlement to service connection for a right knee disability is remanded. 9. Entitlement to service connection for a left lower extremity shin disability is remanded. 10. Entitlement to service connection for a right lower extremity shin disability is remanded. The Board incorporates its discussion from the sections above by reference. We note that arthritis is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. Saunders v. Wilkie, 886 F.3d 1356 (2018). By way of background, the Veteran testified at the March 2021 hearing regarding each of these claimed conditions. We will address them in order. First, for the left and right ankles, the Veteran testified that he began having issues during basic training, including pain and popping. See March 2021 hearing transcript, p. 31. He was given an intermittent profile, and received braces after separation. Id. at p. 38. Turning to the left and right knees, the Veteran through his attorney explained that he had knee issues in bootcamp that coincided with issues of an incorrect shoe size. The Veteran sought initial treatment but there was not a lot to be done during that period. The Veteran continued to experience knee impairment, however, most of his duty assignments after Germany were sedentary in nature. The knees bothered him, but he did not continuously seek treatment in service because they were not a daily issue. Id. at pp. 38-39. Lastly, for the left and right lower extremities, the Veteran through his attorney testified that although there was not medical documentation of shin disabilities in the Service Treatment Records (STRs), there are post-service medical records showing disability. The Veteran's attorney described, "VAMC specifically identifying pain in ankles, pain in knees, MRI done in 2015 regarding the ankles to identify the basis of the actual issue that Mr. [Veteran] has been suffering from." Id. at p. 42. The Veteran through his attorney concluded, "We would be requesting a remand with a Compensation & Pension examination to identify potential relation to military service." Id. at p. 42. Indeed, VA must provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). To fully address the Veteran's contentions, and to assist in fully developing the Veteran's claims, a series of VA examinations with medical opinions for the left and right knees, ankles, and lower extremities to include shins are necessary. The matters are REMANDED for the following action: 1. If the Veteran identifies other evidence, obtain updated copies of the Veteran's VA treatment records, and associate them with the Veteran's claims folder. 2. Please schedule the Veteran for a VA examination to determine the nature and etiology of any disability manifested by chronic itching to the head and scalp. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 3. Please schedule the Veteran for a VA examination to determine the nature and etiology of any bipolar disorder, including as a psychosis and with neuropsychological signs and symptoms associated with anxiety; and/or depression. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The VA examiner should also opine whether any diagnosed psychiatric disability is proximately due to, the result of, or aggravated by the Veteran's service-connected disabilities, including degenerative arthritis of the thoracolumbar spine and degenerative disc disease of the cervical spine. The examiner should provide a rationale for all opinions expressed. 4. Please schedule the Veteran for a VA examination to determine the nature and etiology of any varicose vein disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The Board notes that the Veteran is competent to report that which is capable of lay observation, including seeing bulging veins in both legs and experiencing pain. The examiner should provide a rationale for all opinions expressed. 5. Please schedule the Veteran for a VA examination to determine the nature and etiology of any left and right ankle disability or disabilities. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 6. Please schedule the Veteran for a VA examination to determine the nature and etiology of any left and right knee disability or disabilities. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 7. Please schedule the Veteran for a VA examination to determine the nature and etiology of any left and right lower extremity shin disability or disabilities. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 8. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his attorney an appropriate supplemental statement of the case (SSOC). Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Bodi, 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.