Citation Nr: 21040200 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 03-27 102 DATE: July 2, 2021 ORDER New and material evidence having been received, a claim for service connection for a skin condition is reopened. New and material evidence having been received, a claim for service connection for chronic otitis externa is reopened. Entitlement to service connection for hearing loss is denied. Entitlement to service connection for residuals of a breast reduction is granted. Entitlement to service connection for a skin condition, to include urticaria, is granted. REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for hemorrhoids is remanded. Entitlement to service connection for acrophobia is remanded. Entitlement to service connection for chronic otitis externa is remanded. FINDINGS OF FACT 1. A June 1994 rating decision denied the Veteran's claims for ear pain and skin rashes. No new and material evidence pertinent to the claims were received within one year of the issuance of that decision. The Veteran was notified of the decision and her appellate rights but did not appeal it. Evidence received that time is new and raises a reasonable possibility of substantiating the claims. 2. The Veteran's in-service breast reduction surgery was performed to alleviate complaints of neck and back pain that had their onset during service; the breast reduction surgery resulted in residual scars, pain, and numbness. 3. Resolving all reasonable doubt in her favor, the Veteran's skin condition is etiologically related to service. 4. The Veteran does not have a current diagnosis of hearing loss. CONCLUSIONS OF LAW 1. The June 1994 rating decision became final, but new and material evidence has been received sufficient to reopen the previously denied claim for ear pain. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. The June 1994 rating decision became final, but new and material evidence has been received sufficient to reopen the previously denied claim for a skin rash. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for entitlement to service connection for residuals of a breast reduction have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for entitlement to service connection for a skin condition, to include urticaria, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for entitlement to service connection for hearing loss have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from November 1987 to November 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This decision was issued pursuant to the rules of the legacy appeals system that were in effect prior to the implementation of the Appeals Modernization Act (AMA), which became effective on February 19, 2019. By way of procedural history, the Veteran filed a notice of disagreement with respect to the January 2018 rating decision in March 2018. In September 2019, the RO issued a statement of the case (SOC). The Veteran filed a timely substantive appeal in November 2019, and the matter was certified to the Board in June 2020. In August 2020 and October 2020, however, the Veteran filed multiple VA Forms 10182 in an attempt to withdraw various pending claims from the legacy appeals system and to opt into the AMA appeals system. With respect to the claims for her right knee, hemorrhoids, acrophobia, and the residuals of her breast reduction, the Board informed her in November 2020 correspondence that her requests to opt into the AMA appeals system had been rejected because she had requested to opt into the modernized appeals system more than 60 days after an SOC had been issued in her case. This was also explained in a December 2020 letter. These claims are thus still pending in the legacy appeals system. With respect to her claim for urticaria, the Board notes that a rating decision on urticaria was issued in error in August 2020. Although the rating decision discussed entitlement to service connection for urticaria, the RO meant to adjudicate entitlement to service connection for a separate skin condition. Although she submitted a timely Form 10182 in response to the August 2020 rating decision in October 2020, the RO later informed her in a December 2020 letter that the August 2020 decision had been issued in error and that the decision had been retroactively corrected to discuss the other skin condition instead of urticaria. Accordingly, her claim for service connection for urticaria was dismissed from the modernized appeal system in a March 2021 Board decision. The Board will therefore address the claim on its merits in this decision pursuant to the rules of the legacy appeals system. Last, the Board notes that the Veteran also claimed entitlement to service connection for residuals of a hysterectomy. In a May 2018 Board decision, the Board denied her claim pursuant to the rules of the legacy appeals system. In December 2018, the Court of Appeals for Veterans Claims (Court) granted a Joint Motion for Partial Remand that vacated the May 2018 decision and remanded the matter to the Board. In a May 2019 Board decision, the Board remanded the claim and instructed the RO to undertake additional development. In September 2020, the RO issued a supplemental statement of the case (SSOC) denying her claim. Within 60 days of the issuance of the SSOC, the Veteran submitted a Form 10182. Because it was submitted within 60 days of the SSOC, her hysterectomy claim was eligible for adjudication in the modernized appeals system. Her claim was thus withdrawn from the legacy appeals system. In December 2020, however, the RO issued another SSOC on her hysterectomy. This appears to have been done in error. Regardless, in January 2021, the Veteran received a letter docketing her claim in the AMA system and withdrawing it from the legacy appeals system. The Board denied her claim in a March 2021 decision. As such, this claim is not pending in the legacy system any longer and the Board will not address it herein. Last, the Board notes that since these matters were certified to the Board, additional evidence has been added to the record. This evidence includes VA treatment records. However, in April 2021 the Veteran waived her right to have the case remanded to the RO for review of the additional evidence in the first instance. This matter has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.800(c). New and Material Evidence Historically, the Veteran filed a claim for entitlement to service connection for ear pain and skin rashes in January 1994. In a June 1994 rating decision, her claims for ear pain and skin rashes were denied. With respect to the claimed ear pain, the RO found that there was no current diagnosis of any ear condition. With respect to the claimed skin rashes, the RO noted that no records documented a chronic skin condition in service. The Veteran did not file a timely notice of disagreement to appeal these issues and, as such, the June 1994 rating decision became final. Subsequently, the Veteran filed claims for chronic otitis externa and urticaria in December 2017. Generally, a claim that has been denied by an unappealed decision may not thereafter be reopened. 38 U.S.C. § 7105(c). An exception to this rule exists for cases in which new and material evidence is presented or secured with respect to a claim that has been disallowed, in which case the claim must be reopened and the former disposition reviewed. 38 U.S.C. § 5108. New claims that are based on distinctly and differently diagnosed diseases or injuries than a previously denied claim must be considered independently, despite similar symptoms. Therefore, new and material evidence is not required in such cases. Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008). As a threshold matter, the Board must thus determine whether the Veteran's current claims for chronic otitis externa and skin rashes truly amount to new claims, or whether they should instead be characterized as a petition to reopen the prior claims ear pain and a skin rash. Velez v. Shinseki, 23 Vet. App. 199 (2009). To do so, the Board looks to the factors laid out in the Velez case for guidance, including considerations such as: whether the scope of the current claim encompasses the prior claim; whether the new and previous diagnoses are proper diagnoses versus lay diagnoses; whether medical evidence of the newly claimed diagnosis was of record at the time of the prior denial; whether the prior final denial considered evidence of the newly claimed diagnosis; and whether the newly claimed diagnosis has a "factual basis" that is distinct from the prior diagnosis. See id. A new diagnosis does not necessarily amount to a new claim if the evidence shows that the same disease or injury was in fact adjudicated in a prior claim. See Boggs, F.3d at 1336 (a misdiagnosis cannot be the basis for a new claim). Here, the Board finds that the application of the Velez factors weighs in favor of treating the Veteran's claims as a petition to reopen, rather than as new claims. Regarding the scope and characterization of the prior claims, the Board finds that the Veteran's current claims for chronic otitis externa and urticaria were broadly encompassed by her claims for ear pain and skin rashes. Additionally, the symptoms that she reported after filing her January 1994 claim (e.g., ear pain, hives, scaling of the scalp, and hypopigmentation) are similar to the symptoms that she reported in connection with her most recent claim. Most significantly, the factual bases and contentions regarding her claims appear to be the same. For instance, in recent medical records, she reports that she has been breaking out in hives since service, and that she has a history of hives, scalp rashes, and seborrheic capitis. To that end, she reported in her January 1994 claim that she was treated for a skin rash in 1990; a February 1994 VA examiner noted that she had seborrheic capitis and was treated for hives in 1990. Likewise, in connection with her most recent claim, she argues that she was treated for ear infections during service and that her ear pain symptoms are secondary to service-connected conditions such as tinnitus and rhinitis. Pursuant the February 1994 VA examination, she reported being treated for an ear infection during service and that she believed that her ear pain was secondary to problems caused by working around loud noises. Moreover, although the Veteran was diagnosed with otitis externa after the June 1994 rating decision was issued, the rating decision clearly adjudicated the same symptoms that the Veteran now reports in connection with her recent medical treatment for otitis externa (i.e., pain and discomfort). Ultimately, the Veteran's claimed conditions share several symptoms with the conditions that were adjudicated in the June 1994 rating decision. As such, the Board finds that they are not true "new" claims but should instead be construed as claims to reopen her prior claims. Accordingly, new and material evidence is required to reopen her claims. "New" evidence means evidence not previously submitted to agency decisionmakers, and "material" evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). This is a "low threshold" in which the phrase "raises a reasonable possibility" should be interpreted as "enabling rather than precluding reopening." Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). The credibility of the newly-submitted evidence is presumed, though not blindly accepted as true if patently incredible. Justus v. Principi, 3 Vet. App. 510 (1992). To that end, additional evidence submitted since the June 1994 rating decision includes lay statements, private treatment records, and VA treatment records. This evidence is new, as it was not of record at the time of the prior June 1994 rating decision. The evidence is also material, as it relates to previously unestablished elements of her claims (i.e., whether she has a diagnosed ear condition and whether her skin rash had its onset during her service). For instance, the additional evidence reflects recent diagnoses of otitis externa and complaints of ear pain, as well as statements indicating that she has frequently experienced skin hives and other rashes since service. As such, new and material evidence has been received, and reopening of the claims is warranted. As set forth below, the Board will adjudicate the claim for urticaria, but additional development is warranted prior to reviewing the otitis externa claim on its merits. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three criteria: (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). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of each veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a). The Board must assess the credibility of all evidence to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not afforded to each piece of evidence in the record; every item of evidence does not have the same probative value. Although the Board is prohibited from finding lay evidence not credible solely based on a lack of contemporaneous medical records, credibility can generally be evaluated by a showing of interest, bias, or inconsistent statements. See Caluza v. Brown, 7 Vet. App. 498, 510-11 (1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Breast reduction residuals The Board will first address the Veteran's claim for service connection for residuals of a breast reduction surgery that she underwent during service. At the outset, the Board notes that the Veteran originally filed a claim for service connection for scars on her breasts in January 1994, which was denied in June 1994. This decision was ultimately affirmed in a September 1997 Board decision, which became final. However, service treatment records specifically related to her breast reduction surgery were later added to the claims file in December 2019. These official service department records from 1989 existed at the time of the Board's September 1997 decision and are related to her in-service breast reduction but were not associated with the record until 2019, 25 years after she initially filed her claim for service connection. Moreover, the Veteran provided sufficient information for VA to identify and obtain these records at the time of her initial claim. As such, notwithstanding the finality of the Board's September 1997 decision, the Board will reconsider her claim without determining whether new and material evidence has been submitted pursuant to 38 C.F.R. § 3.156(c). Here, the Veteran asserts that she underwent breast reduction surgery due to back and neck pain caused by the size of her breasts and, as a result of the surgery, she has bilateral breast scarring and a loss of feeling in her left breast. However, in the June 1994 rating decision on the Veteran's breast reduction, the RO referred to her breast reduction surgery as "elective" and not necessitated by medical need. As set forth above, service connection will be granted for a disability caused or aggravated by a disease or injury in service. 38 U.S.C. § 1110. At all times relevant to this appeal, VA regulations have provided that service connection would not be granted for the usual effects of medical and surgical treatments in service having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars. 38 C.F.R. § 3.306(b)(1). The Veteran's January 1987 enlistment examination does not indicate that she had back or neck pain that was caused by the size of her breasts and does not note any abnormalities with respect to her breasts. Two years later, the Veteran was seen at the plastic surgery clinic at Randolph Air Force Base in January 1989 with respect to her breast size. More specifically, she complained that they were too large and caused her back and neck to ache. After obtaining her informed consent, the base plastic surgery clinic scheduled a bilateral breast reduction surgery that was to take place in April 1989. In April 1989 service treatment records, she again reported that her breasts were so large that they caused back strain before undergoing her bilateral breast reduction on April 6, 1989. Post-operative service treatment records indicate that she had residuals scars from the surgery. For instance, May 1989 treatment records note heavy keloid scarring following her reduction mammoplasty, while September 1993 service treatment records reflect semi-circular scars on the bilateral breasts secondary to her breast reduction. The provisions of 38 C.F.R. § 3.306(b)(1) would only serve to bar service connection for her breast reduction surgery if the surgery were for a disability that pre-existed enlistment. Here, however, there is no evidence that the conditions that necessitated the Veteran's breast reduction surgery were pre-existing. Because no abnormalities with her breasts, back, or neck were reported on her enlistment examination when she was accepted for service, she is presumed to have been in sound condition when she entered service. That presumption can only be rebutted by clear and unmistakable evidence that the disability pre-existed service and was not aggravated therein. 38 U.S.C. §§ 1111, 1137. Here, on the other hand, she reported no symptoms of neck and back pain related to the size of her chest until 1989. Accordingly, her breast reduction surgery was not done to ameliorate the effects of a pre-existing condition, and service connection is available for a residual disability resulting from her breast reduction surgery. Moreover, it is clear from the record that this surgery was done out of medical necessity due to the pain in her back and neck. Furthermore, the evidence of record unequivocally demonstrates that the Veteran's breast reduction surgery resulted in scars, as well as other residual symptoms like pain and numbness. For instance, in February 1995 correspondence, the Veteran stated that she had six sets of scars on her breasts from her breast reduction surgery, which had caused itching and pain. In a January 2003 letter, she indicated that she has not had feeling in her left breast since the surgery. As such, the preponderance of the evidence weighs in favor of finding that the Veteran has current residuals from her April 1989 breast reduction surgery. Service connection must thus be granted. 2. Skin condition The Board now turns to the Veteran's claim for service connection for urticaria. As set forth above, this claim has been reopened following the receipt of new and material evidence regarding the etiology of the Veteran's history of skin rashes. Generally, the Veteran has alleged that she has frequent allergic reactions that give her hives. She has also stated that she had a "skin condition" while she was in the military and that she has continued to have skin conditions up until the present. Because the record reflects diagnoses for various skin conditions, such as urticaria and dermatitis, the Board has recharacterized the claim to a claim for a skin condition, to include urticaria, however diagnosed. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Here, service treatment records reflect that the Veteran was treated for a rash on her backs and legs in March 1990 while stationed at Randolph Air Force Base. Although the records are difficult to read, they reflect that she was diagnosed with urticaria at that time. Shortly after being discharged from service, she underwent a VA examination in February 1996. At that time, the VA examiner noted that she reported being treated with Benadryl for hives in 1990 and that there was scaling on the skin of her scalp. Thereafter, she continued to receive treatment for rashes on her skin. For instance, in February 1999 she was treated for a fungal-like rash on her forearm. In a January 2004 treatment record from an army health clinic, she reported that her scalp had felt flaky and itchy for the past year. She was diagnosed with dermatitis of the scalp and referred the dermatology clinic. Recent VA treatment records reflect that she has been prescribed diclofenac topical gel, an antihistamine which she applies to her lower extremities four times a day. As set forth above, the Veteran previously attended a VA examination in February 1994 with respect to her claimed skin rash. At that examination, the VA examiner noted that her skin was normal other than scaling on her scalp, which she had noticed for about the past year. Ultimately, he concluded that her scalp was normal without providing any opinions regarding the etiology of her skin rashes. In July 2020, the Veteran was again afforded a VA examination for skin conditions. The VA examiner diagnosed her with urticaria by history. She reported that she began having spontaneous outbreaks in 1990, that she has intermittent flare-ups of her skin condition that cause welts, itching, and irritation on different parts of her body. She also stated that she gets relief using over-the-counter medicines like Benadryl and that she has at least six to nine flare-ups a year, if not more. At the time of the examination, she had no characteristic lesions, but she also indicated that she was constantly or near constantly using antihistamines. The July 2020 VA examiner provided negative nexus opinions with respect to the etiology of the Veteran's skin condition. In this regard, the VA examiner opined that it was less likely than not that her skin condition was incurred in or otherwise related to her time in service because she had not complained of, been diagnosed with, or received treatment for urticaria since March 1990 and no skin conditions were noted on examination. The Board finds that this opinion, however, is entitled to little probative weight. First, the examiner's opinion is conclusory and fails to include a sufficiently detailed rationale. Second, the examiner states that the Veteran has not complained of hives since being treated for them in March 1990 but entirely fails to address the Veteran's lay statements regarding her skin. To that end, the Veteran is competent to describe symptoms including hives, itching, or rashes on her skin. Her statements regarding the onset and nature of her skin condition have been consistent over time and, as such, the Board finds them to be highly credible. As such, the Board affords the Veteran's lay statements regarding the onset and symptomatology of her skin condition more probative value than the July 2020 VA examiner's opinion. Last, the Board notes that although no skin lesions were present during the VA examination, she has reported that her skin condition will flare-up multiple times a year. Considering the evidence in the light most favorable to the Veteran, the Board finds that the evidence is approximately in equipoise with respect to the nature and etiology of her skin condition. The Board acknowledges that the record does not contain any probative medical opinions discussing whether her skin condition is directly related to service. Nonetheless, medical evidence is not categorically required to satisfy the nexus element of the service connection framework. See Davidson v. Shinseki, 581 F.3d 1313 (2009). Here, the Board finds the Veteran's statements regarding the onset and continuity of her skin condition to be competent and credible and, in this instance, sufficient to establish service connection. Indeed, the Veteran reported experiencing scaly skin immediately after being discharged from service and continued to report various skin irritation for several years thereafter. Ultimately, affording her the benefit of the doubt, the evidence indicates that the Veteran's skin condition had its onset during service and that it has intermittently continued since that time. Service connection is thus warranted. 3. Hearing loss The Veteran also asserts that she is entitled to service connection for hearing loss due to military noise exposure. Her service personnel records confirm that she worked as an aircraft mechanic during her time in the Air Force and contain various in-service audiograms, which confirm her exposure to noise during service. Thus, her in-service exposure to noise is not in question. However, under 38 C.F.R. § 3.385, hearing loss is considered a disability for VA purposes when pure tone thresholds in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies is 26 decibels or greater; or when speech recognition scores using the Maryland CNC test are less than 94 percent. At a December 2017 VA examination, the Veteran's pure tone thresholds, measured in decibels, were as follows in the right and left ears at the following frequencies: Hertz 500 Hertz 1000 Hertz 2000 Hertz 3000 Hertz 4000 Hertz Right 10 10 10 10 15 Left 10 10 5 15 15 Additionally, speech discrimination scores were 100 percent in both ears. Unfortunately, these results do not indicate that the Veteran has a current diagnosis of hearing loss in either ear for VA purposes. First, pure tone thresholds at 500, 1000, 2000, 3000, and 4000 Hertz are all below 40 decibels. Indeed, the highest pure tone threshold either ear is 15 decibels (i.e., none are above 26 decibels). Moreover, speech recognition scores are greater than 94 percent in both ears. A comparison between these findings and the criteria found in 38 C.F.R. § 3.385 indicates that current hearing loss is simply not present in either ear for VA purposes. While the Board recognizes the Veteran's belief that she has a current hearing loss disability, she is not competent to provide such a diagnosis, as such requires specialized testing in accordance with VA regulations. In the absence of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Here, the evidence of does not indicate that the Veteran has ever been diagnosed with hearing loss in either ear for VA purposes. Accordingly, service connection for hearing loss is not warranted. REASONS FOR REMAND 1. Right knee, hemorrhoids, and acrophobia With respect to the Veteran's claims for a right knee disability, hemorrhoids, and acrophobia, remand is warranted because there is insufficient medical evidence with respect to these claims. VA has a duty to assist claimants in obtaining evidence to substantiate their claims. This duty may include scheduling a medical examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, the Veteran asserts that due to her work as an aircraft mechanic, her right knee developed problems later in life. As set forth above, personnel records confirm that she served as an aircraft mechanic during service. Additionally, her service treatment records reflect that she received extensive mental health treatment related to a simple phobia (i.e., fear of heights) in connection with her work as an aircraft mechanic. Last, service treatment records indicate that she complained of symptoms such as constipation and difficulty with bowel movements during service. Moreover, the Veteran's recent VA treatment records reflect that she has complained of pain and pressure in her right knee. She reports that she has limited motion in this knee. Additionally, she has asserted that she continues to suffer from fear of heights. Last, VA private treatment records reflect that she was recently diagnosed with hemorrhoids that required surgical treatment. At this juncture, however, remand is required, as no VA examination has been provided with respect to any of these claims. To that end, it is unclear whether the Veteran still suffers from acrophobia, what the exact nature and etiology of her right knee disability is, and whether her complaints of constipation in service are related to her recent hemorrhoids. Given the aforementioned evidence, however, the Board finds that remand is warranted to obtain medical examinations and opinions with respect to these questions. See McLendon, 20 Vet. App. at 83-86. 2. Otitis externa Last, as set forth previously in this decision, the Veteran asserts that she is entitled to service connection for chronic otitis externa. The record also indicates that she has asserted that her otitis externa is secondary to a service-connected condition, such as tinnitus. Service treatment records reflect that she was treated for ear pain in February 1990, November 1990, and December 1990. She was diagnosed with serous otitis, as well as Eustachian tube dysfunction. After service, she received treatment for various ear conditions, such as otitis externa, otitis media, and ear pain. To date, however, no VA examination has been obtained to determine whether there is a nexus between her in-service complaints of ear pain and her current ear pain, or whether her ear pain is secondary to a service-connected condition. Moreover, the Board notes that the Veteran is currently entitled to service connection for chronic sinusitis and rhinitis. It is unclear whether the symptoms of ear pain that she attributes to chronic otitis externa are instead attributable to her service-connected sinusitis or rhinitis conditions. For instance, when describing her symptoms of rhinitis, she has described feelings of ear and nasal congestion. In the interest of assembling clear and reliable findings, the Board requests for the examiner to also opine as to whether the Veteran's symptoms of ear pain are manifestations of a service-connected disability, such as sinusitis or rhinitis, or whether her symptoms of ear pain are instead attributable to a separate condition. Accordingly, the matters are REMANDED for the following action: 1. After obtaining proper authorization, obtain and associate with the claims file any outstanding VA treatment records and outstanding, relevant private treatment records. 2. Thereafter, arrange for the Veteran to undergo VA examinations with an appropriate examiner(s) to obtain medical findings addressing the nature and etiology her claimed right knee, acrophobia, hemorrhoid, and otitis externa disabilities. After reviewing the claims file in its entirety and examining the Veteran, the VA examiner(s) must complete the following directives. With respect to the claim for a right knee disability: (a.) Identify any diagnosable disability associated with the Veteran's right knee. The examiner is reminded that a disability does not require a known diagnosis or pathology; it only requires that the condition results in a functional limitation in earning capacity. If the Veteran does not have a diagnosable condition with respect to her right knee, but has pain only, determine whether the pain causes functional loss. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). (b.) For each identified condition, provide an opinion as to whether it is at least as likely as not (approximately 50 percent or greater probability) that the Veteran's right knee disability had its onset during or is otherwise related to active service. This opinion must address the Veteran's assertion that her work as an aircraft mechanic during service ultimately caused her to develop a right knee disability. With respect to the claim for acrophobia: (a.) Identify any diagnosable disability associated with a fear of heights, including acrophobia, that has been present during the pendency of this appeal, even if the disability has since resolved. (b.) For each identified condition, provide an opinion as to whether it is at least as likely as not (approximately 50 percent or greater probability) that the Veteran's disability had its onset during or is otherwise related to active service. This opinion must address the Veteran's contentions regarding her fear of heights and her service treatment records reflecting treatment for acrophobia. With respect to the claim for hemorrhoids: (a.) Identify any diagnosable disability associated with hemorrhoids that has been present during the pendency of this appeal, even if the disability has since resolved. (b.) For each identified condition, provide an opinion as to whether it is at least as likely as not (approximately 50 percent or greater probability) that the Veteran's disability had its onset during or is otherwise related to service. This opinion must address the Veteran's contentions that her symptoms of constipation and difficulty with bowel movements during service are related to her current disability. With respect to the claim for chronic otitis externa: (a.) Identify any diagnosable disability associated with ear pain, such as otitis externa, that has been present during the pendency of this appeal, even if the disability has since resolved. In doing so, opine as to whether the Veteran's complaints of ear pain are manifestations of other service-connected conditions, such as sinusitis or rhinitis, or if ear pain is a manifestation of a separate disability or disabilities. (b.) For each identified condition (i.e., not a manifestation of another service-connected disability), provide an opinion as to whether it is at least as likely as not (approximately 50 percent or greater probability) that the Veteran's disability had its onset during or is otherwise related to service. (c.) For each identified condition, provide an opinion as to whether it is at least as likely as not (approximately 50 percent or greater probability) that the Veteran's disability has been (1) caused by, or (2) aggravated by a service-connected disability, such as tinnitus, rhinitis, or sinusitis. A complete rationale for these opinions must be provided. All opinions should be based on examination findings, historical records, and medical principles, as well as the Veteran's lay statements. The examiner should fully articulate a sound reasoning for all conclusions made. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Rademacher, 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.