Citation Nr: 21042243 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 16-52 795 DATE: July 12, 2021 ORDER New and material evidence sufficient to reopen a claim for entitlement to service connection for Lyme disease has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen a claim for entitlement to service connection for a left knee disability has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen a claim for entitlement to service connection for a right knee disability has been received, and to that extent only, the claim is granted. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depressive disorder, is granted. REMANDED Entitlement to service connection for Lyme disease is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. FINDINGS OF FACT 1. A June 2002 rating decision denied a claim for service connection of Lyme disease, a left knee disability, and a right knee disability. The Veteran was notified of his rights but did not appeal or submit new and material evidence during the applicable one-year appellate period. 2. For the Lyme disease, a left knee disability, and a right knee disability, evidence received since June 2002 is not cumulative or redundant of the evidence previously of record, and raises a reasonable possibility of substantiating the Veteran's claim of service connection for Lyme disease, a left knee disability, and a right knee disability. 3. The Veteran has two acquired psychiatric disorders, diagnosed as PTSD and depressive disorder, that are, as likely as not, causally related to the Veteran's active service. CONCLUSIONS OF LAW 1. The June 2002 rating decision is final. 38 U.S.C. §§ 7104, 7105 (2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2001). 2. New and material evidence sufficient to reopen the claims of service connection for Lyme disease, a left knee disability, and a right knee disability have been received since June 2002, and the claims are reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2020). 3. The criteria for entitlement to service connection for post-traumatic stress disorder (PTSD) and depressive disorder have been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from January 1998 to January 2002, with subsequent service in the Air Force Reserve to March 2009. This matter comes before the Board of Veterans' Appeals (Board) from an August 2013 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. With respect to the Veteran's original claim for service connection for PTSD, the United States Court of Appeals for Veterans Claims (Court) has held that claims for service connection for PTSD encompass claims for service connection for all psychiatric disabilities. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). As the Veteran has several psychiatric diagnoses in her treatment records, the Board has expanded the Veteran's original claim for service connection for PTSD to a claim of service connection for an acquired psychiatric disorder, to include PTSD, depressive disorder, anxiety disorder, and a mood disorder. By way of background, the Veteran originally filed a claim for service connection for Lyme disease and both knees in February 2001, and that claim was eventually denied in a June 2002 rating decision. That decision was not appealed within one year, and thus became final. As such, then, the last final denial for the lumbar back claim is the June 2002 rating decision. In March 2012, the Veteran filed a claim to reopen the Lyme disease and bilateral knee disabilities, and this is the appeal stream now active before the Board. The Veteran testified at a virtual Board hearing before the undersigned Veterans Law Judge (VLJ) in April 2021; a transcript of that hearing is associated with the claims file. In any case involving a finally denied claim, the Board must address whether new and material evidence has been received to reopen before addressing the merits of the claim, regardless of whether or not the agency of original jurisdiction (AOJ) has already addressed the question. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Wakeford v. Brown, 8 Vet. App. 237, 23940 (1995). Veterans Claims Assistance Act of 2000 (VCAA) 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) (2020). With respect to claims to reopen, VA is further required to provide notice of the definition of new and material evidence. Kent v. Nicholson, 20 Vet. App. 1 (2006). However, VA is no longer required to provide notice of the element or elements that were found insufficient or the information and evidence necessary to substantiate the insufficient element or elements. See 38 U.S.C. § 5103(a)(1); VAOPGCPREC 6-2014 (Nov. 21, 2014); see also Akers v. Shinseki, 673 F.3d 1352, 1358 (Fed. Cir. 2012). 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). Petition to Reopen In June 2002, VA denied the original claim of entitlement for service connection for Lyme disease and bilateral knee disabilities. The claims were originally denied because the evidence did not show an incident or injury in service. The RO reviewed the Veteran's available service treatment records (STRs), VA treatment records, and his statements regarding the disability. The Veteran did not file a notice of disagreement (NOD) or submit new and material evidence within the one-year appeal period following those decisions. He also did not assert there was clear and unmistakable error in the rating decision. Therefore, the decision became final. 38 U.S.C. § 7105(c) (2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2002). The Veteran sought to reopen the claim in March 2012. The RO reviewed the Veteran's available service treatment records (STRs), VA treatment records, and his statements regarding his right shoulder and lumbar back disabilities. The RO denied the claim in August 2013, and the Veteran was notified on august 13, 2013. The Veteran filed a notice of disagreement (NOD) in October 2013. VA issued a statement of the case (SOC) in August 2016. The Veteran perfected an appeal to the Board in October 2016 and the appeal was certified before the Board in June 2019. The Board is required to address new and material claims in the first instance. The Board has the jurisdiction to address a new and material issue and to reach the underlying de novo claims. If the Board determines that new and material evidence has not been received, the adjudication of the particular claim ends, and further analysis is neither required nor permitted. Any decision that the AOJ may have made with regard to a new and material claim is irrelevant. Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). Thus, the Board will adjudicate this new and material issue in the first instance. New evidence is defined as existing evidence not previously submitted to VA since the last final denial, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2020). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Additionally, the United States Court of Appeals for the Federal Circuit has noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). Only evidence presented since the last, final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273, 284 (1996). The Board considers the last, final denial to be the October 2008 rating decision for the lumbar back disability and the February 2012 rating decision for the right shoulder disability. For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). However, VA is not bound to consider credible the patently incredible. Duran v. Brown, 7 Vet. App. 216 (1994). Claim Reopened The evidence of record in June 2002 consisted of service records, including personnel and medical records, and VA treatment records. The evidence of record at that time did establish diagnoses of a lumbar back disability, but it did not establish a nexus back to service for either. Since the June 2002 rating decision, the Veteran's file has additional VA and private medical records that have been attached to the claims file. Also, the Veteran provided testimonial evidence during her April 2021 hearing with the undersigned Veterans Law Judge. These VA medical records show continuing treatment for the Veteran's bilateral knees and symptoms possibly indicative of Lyme disease through to the present. This new evidence is not cumulative or redundant of the evidence previously of record. The Board is reminded in this regard that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade. And further, that consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied. This newly received evidence basically provides a more complete picture as to the nature of the Veteran's lumbar back disability in question, and under the low threshold standard could reasonably trigger the Secretary's duty to assist. Id. at 118. Therefore, assuming its credibility for the purpose of the threshold question of whether the claim can be reopened, the newly received evidence raises a reasonable possibility of substantiating the Veteran's claim of service connection for Lyme disease, a left knee disability, and a right knee disability. As new and material evidence has been received, reopening of the previously denied claims of entitlement to service connection for Lyme disease, a left knee disability, and a right knee disability is warranted. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2020). To that extent only, the claim to reopen for service connection for Lyme disease, a left knee disability, and a right knee disability is granted. Service Connection for an Acquired Psychiatric Disorder The Veteran seeks service connection for PTSD, asserting that service in Kosovo in 1999 and then later Saudi Arabia immediately following September 11, 2001, has contributed to symptoms of PTSD. The Veteran has been in treatment for psychiatric disorders since 2008, and received a formal VA diagnosis of PTSD in 2018. The Veteran later stated that she endured military sexual trauma from unwanted sexual attraction while stationed in Germany. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must 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-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (2020); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). In addition to the above, establishment of service connection for PTSD, as opposed to other acquired psychiatric disorders, requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). See also Cohen v. Brown, 10 Vet. App. 128 (1997). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(2). The Board notes that VA, effective March 19, 2015, amended the portion of the Rating Schedule dealing with mental disorders so as to replace outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 (August 4, 2014). VA directed that the changes be applied only to applications for benefits received by VA or pending before the agency of original jurisdiction (AOJ) on or after August 4, 2014, but not to claims certified to, or pending before, the Board, the Court of Appeals for Veterans Claims (CAVC), or the United States Court of Appeals for the Federal Circuit. As the Veteran's original PTSD claim was made prior to August 4, 2014, the diagnosis of PTSD pursuant to DSM-IV is applicable to this appeal. See 38 C.F.R. § 4.125(a). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. In making that decision, the Board must determine the probative weight to be ascribed as among multiple medical opinions, and state the reasons and bases for favoring one opinion over another. See Winsett v. West, 11 Vet. App. 420, 424-25 (1998); see also Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). This responsibility is particularly important where medical opinions diverge. The Board is also mindful that it cannot make its own independent medical determinations, and that there must be plausible reasons for favoring one medical opinion over another. See Evans at 31; see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Evidence and Analysis The Veteran's service treatment records are negative for complaints or findings of a psychiatric disorder. The Veteran received an initial VA PTSD examination in June 2013. This examiner, a VA psychologist, noted at the outset that the Veteran's symptoms do not meet the diagnostic criteria for DSM-IV, and that the Veteran has a diagnosis of mood disorder, not otherwise specified (NOS). The primary symptoms noted were a combination of irritability, anxiety, and depression on a daily basis. No evidence of a traumatic brain injury was noted. The examiner noted service in Saudi Arabia shortly after September 11, 2001 and after her return, reports of increase irritability and strained family relationships. The examiner did not consider the Saudi service to be a sufficient stressor under DSM-IV criteria. The Veteran saw VA health care providers in 2006 and 2007 but did not report any mental health symptoms. This examiner provided a negative opinion for service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran's mood disorder was incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale was that the Veteran was deployed to the country where her stressor occurred not during a time of war or combat, and the Veteran had not been exposed to any direct or indirect enemy fire. The Veteran submitted in March 2020 a lay statement in support of her PTSD claim outlining her stressors, including the previous one from her Saudi Arabian deployment and adding another one related to her deployment to Operation Allied Force in Kosovo in 1999. The Veteran received a private psychiatric examination from a psychiatrist in August 2020, and a formal diagnosis of PTSD in accordance with DSM-5 and also insomnia disorder was made. This private examiner indicated she had reviewed the entirety of the Veteran's claims file. The examiner found the Veteran met two different stressors for Criterion A for a diagnosis of PTSD, the Kosovo experience and the Saudi Arabia experience. Symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control were noted. This examiner provided a positive opinion for service connection, saying it was more likely than not that the Veteran's in-service experiences, in Kosovo in 1999 and Saudi Arabia in 2001, led to PTSD. The examiner's rationale was that her PTSD symptoms had associated with her in-service trauma stressor events and were deeply ingrained in her overall psychopathology and persist in causing current social and occupational impairment. The Veteran received another VA PTSD examination in October 2020 from a VA psychologist. This examiner reviewed the Veteran's entire claims file, to include all of her recent records related to her psychiatric disorders, and diagnosed PTSD in accordance with DSM-5. The examiner noted that previous diagnoses of insomnia, anxiety disorder, and panic disorder were subsumed into her PTSD diagnosis. This VA psychologist also diagnosed depressive disorder due to the Veteran's chronic pain syndrome, related to her service-connected diagnosis of fibromyalgia. This examiner noted it was impossible to differentiate the symptoms, because the conditions have overlapping symptoms with comorbid effects. The examiner noted there is a clinical association with all these psychiatric diagnoses. The VA examiner considered occupational and social impairment to be with deficiencies in most areas, such as work, school, family relations, judgment, think, and/or mood. This examiner considered the previously noted Kosovo and Saudi Arabia deployment stressors to be valid for Criterion A for PTSD, and also noted a third valid stressor, that of PTSD pertinent to military sexual trauma from the Veteran's duty station in Germany from 1998-2000. The examiner considered the latter to be her initial PTSD stressor, and each of the following two built upon the earlier stressor events. Symptoms of depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control were noted. This VA examiner provided a positive opinion for service connection, saying it was more likely than not that the Veteran's PTSD was due to her described service stressors, and also that the Veteran's depressive disorder, described as due to the Veteran's chronic pain syndrome, was proximately due to the Veteran's service-connected fibromyalgia. The examiner's rationale for the secondary service connection of the depressive disorder included references to medical literature that posit links between fibromyalgia and PTSD and other psychiatric illness due to symptom commonality. The examiner's general theory on the etiology was that both fibromyalgia and PTSD are associated with common antecedent traumatic experiences, and here the PTSD predates the fibromyalgia, and the depressive condition was due to the chronic pain syndrome as part of the Veteran's fibromyalgia. The Board notes the April 2021 testimony of the Veteran especially in relation to her stresses and fears during active service and considers this testimony to be highly probative, as it corroborates the symptoms and history the Veteran provided in her earlier VA examinations. The Board notes the Federal Circuit has deemed that a Veteran can testify as to his own psychiatric symptoms and history. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (at least on chronicity of symptoms in service and continuity of symptoms after service questions); see also Culver v. Derwinski, 3 Vet. App. 292 (1992) (nervous breakdown soon after service). In order to be competent, the individual must have personal knowledge, derived from his/her own senses, of what is being attested; "[c]ompetent testimony is thus limited to that which the witness has actually observed, and is within the realm of his personal knowledge." Layno v. Brown, 6 Vet. App. 465, 471 (1994). Here, the Board considers the July 2013 VA examination to be of limited probative value, because of its very limited discussion of the Veteran's service experiences, the incomplete review of the Veteran's record, and the apparent disregard for the Veteran's statements about her record. In addition, the fact that the examiner left the examination report not answered about two key criteria for PTSD without explaining the gap or absence implies an incomplete report at best. As such, the Board notes the finding of no diagnosis of PTSD, but the examiner went no further in considering all possible diagnoses, given the claim. In addition, the examiner noted that he considered the Veteran's profile during the assessment to be possibly invalid because the Veteran misinterpreted a large number of questions. It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). Here, because of the inadequate discussion of the findings of the examination, the Board finds that this examination to be of very limited probative value. Id. Furthermore, because the VA examiner here failed to consider, or at a minimum, record the Veteran's experiences in Germany, Kosovo, and Saudi Arabia, the examiner's opinion has failed to consider critical information necessary for a diagnosis or its denial. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (medical opinion based upon an inaccurate factual premise has no probative value). The Board considers the September 2020 private psychiatric examination and October 2020 VA examination to be of considerable probative value. To have probative value, a medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In each of these two examinations, the examiner conducted a thorough interview and analysis and provided a reasoned opinion based on examination of the Veteran's medical file and other records. The examiner for each noted the Veteran's symptoms and history against the periods of active service pertinent to the claim and wrote a sound opinion in favor of service connection. A medical opinion will be considered adequate when it is based upon consideration of the Veteran's prior medical history and examinations and provides a sufficiently detailed description of the disability so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (internal quotation marks omitted); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). In this case, the Board finds that the evidence is at least, as a minimum, in equipoise as to whether the Veteran has a current diagnoses of an acquired psychiatric disorder, to include PTSD and depressive disorder, related to active service. The Veteran's lay statements as to her experiences in service have been consistent with her duties and experiences in active service, which have been corroborated by the Veteran's testimony and her service personnel and medical records. The Board considers the September 2020 and October 2020 examinations and positive opinions to outweigh the negative opinion from the conclusory July 2013 VA examination. Additionally, the Board gives strong weight to the Veteran's April 2021 testimony before the undersigned Veterans Law Judge, which corroborates the facts shown in the Veteran's medical and personnel records along with the highly probative medical examinations and opinions of September 2020 and October 2020. Therefore, resolving reasonable doubt in the Veteran's favor, it is at least as likely as not that the Veteran has a diagnosis of PTSD and a diagnosis of depressive disorder, each of which is linked to the Veteran's service. The Veteran is therefore entitled to the benefit of the doubt. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is warranted for acquired psychiatric disorders diagnosed as PTSD and depressive disorder. REASONS FOR REMAND 1. Entitlement to service connection for Lyme disease is remanded. 2. Entitlement to service connection for a left knee disability is remanded. 3. Entitlement to service connection for a right knee disability is remanded. The Veteran filed to reopen her previous denied claims for service connection for Lyme disease, the left knee, and the right knee, but was denied in an August 2013 rating decision. VA had provided a May 2002 general examination for the Veteran following her separation from active service in January 2002. However, the examiner noted there was no claims file to review, to include service medical records, and the information on the history of the claimed disabilities came only from the Veteran during the examination itself. Regarding the Lyme disease claim, the examiner noted that even though the Veteran had tested positive for Lyme disease at the time, the Veteran's claim was denied because the examiner had no evidence of the physical skin characteristics of Lyme disease tick bites, and that the Veteran had no records of complaints of pain or arthralgias associated with Lyme disease. However, the Board notes the Veteran's medical records are replete with complaints of pain and arthralgias since active service, and does note also that some of these pain histories may be associated with other disabilities, whether service-connected or not. In addition, the Veteran had another Lyme disease assay in 2012, which again showed positive antibodies for Lyme disease. Regarding the knee disability claims, again the examiner had no service records to review and bilateral pain in the knees was noted, with the remark that it was of unknown etiology, with no further comment. Subsequent examinations, both VA and private, have diagnosed knee disabilities in each knee at different times, but no examination with an opinion for service connection for either knee has been performed since then. Degenerative arthritis in each knee has also been diagnosed by x-ray. Service connection may be established for a current disability on the basis of a presumption that certain chronic diseases, to include arthritis or degenerative disc disease, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For arthritis, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). Service connection for degenerative arthritis can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). For a chronic disease to be considered to have been "shown in service," there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. The Board also takes notice of the recent precedential Federal Circuit case, Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), which held that pain alone may constitute a disability for VA compensation purposes when it results in "functional impairment of earning capacity." Id. at 1368. The Federal Circuit found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability." In other words, where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. VA is obligated to develop and consider all theories of entitlement that are raised by the record or by the claimant. See Robinson v. Mansfield, 21 Vet. App. 545 (2008). VA must examine the record with a view towards ascertaining whether the claimant or the evidence raises consideration of any theory of entitlement, regardless of specific disability claims. VA must provide an examination that is adequate for rating purposes. Barr v. Nicholson, 21 Vet. App. 303 (2007). Based on the medical evidence in the record, the claim must remanded for comprehensive examinations and opinions to address all theories of entitlement for the Veteran's service connection claims for her Lyme disease and for the bilateral knees. The matters are REMANDED for the following action: 1. Make appropriate efforts to obtain and associate with the claims file any updated private or VA medical records identified and authorized for release by the Veteran. 2. After the record search is complete, and any new records are added to the claims file, schedule a VA examination by a VA medical professional with the expertise necessary to address the nature and etiology of the Veteran's Lyme disease and residuals. The claims file must be made available to and reviewed by the examiner. Based on the review of the Veteran's entire record, the examiner should provide an opinion as to the following: Whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's claimed Lyme disease and any residual disabilities had its onset in service or is otherwise related to any in-service disease, event, or injury? Attention is invited to the positive Lyme disease laboratory testing immediately after the April 2001 event and also the presence of Lyme antibodies in laboratory testing subsequently in 2012. 3. Schedule a VA examination by a VA medical professional with the expertise necessary to address the nature and etiology of the Veteran's the Veteran's claimed bilateral knee disabilities, to include all orthopedic and neurological manifestations. The claims file must be made available to and reviewed by the examiner. A note that it was reviewed should be included in the report. Based on the review of the Veteran's entire record, the examiner should provide an opinion as to the following: Whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's claimed knee disabilities had their onset in service or are otherwise related to any in-service disease, event, or injury? Attention is invited to the Veteran's reports and statements of chronic pain in her knees. The Board takes notice of the recent precedential Federal Circuit case, Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), which held that pain alone may constitute a disability for VA compensation purposes when it results in "functional impairment of earning capacity." Id. at 1368. When considering the evaluation, the examiner is to carefully consider the Veteran's testimony before the undersigned Veterans Law Judge, lay statements of record, VA treatment records, and private treatment records and evaluations. The examiner should view the Veteran as a reliable historian as to her service and her reports of her activities and symptoms in and since service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A detailed rationale supporting the examiner's opinion should be provided. In forming the opinion, the examiner must consider all lay statements of record. If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required or the examiner does not have the needed knowledge or training). Jones v Shinseki, 23 Vet. App. 382 (2010). The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 4. Thereafter, readjudicate the issues on appeal. If the determination remains unfavorable to the Veteran, she and her representative should be furnished a supplemental statement of the case which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and her representative should be afforded the applicable time period to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369, 372 (1999). (CONTINUED ON NEXT PAGE) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Setter, 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.