Citation Nr: 22018276 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 19-37 969 DATE: March 28, 2022 ORDER Entitlement to an effective date prior to June 4, 1998 for the grant of service connection for bilateral hearing loss is denied. Entitlement to service connection for acute maxillary sinusitis is granted. Entitlement to service connection for rhinitis is granted. REMANDED Entitlement to service connection for right leg fungus is remanded. Entitlement to service connection for left leg fungus is remanded. Entitlement to service connection for tinea pedis of the right foot is remanded. Entitlement to service connection for tinea pedis of the left foot is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with mood disorder, posttraumatic stress disorder (PTSD), and alcohol use disorder is remanded. Entitlement to service connection for multiple joint pain, claimed as joint condition (nonspecific), including as due to an undiagnosed illness is remanded. Entitlement to a compensable rating for bilateral hearing loss is remanded. FINDINGS OF FACT 1. The Veteran filed to reopen a previously denied claim of entitlement to service connection for bilateral hearing loss on January 17, 2018. 2. In a June 2018 rating decision, service connection for bilateral hearing loss was granted, effective January 17, 2018, the date VA received the Veteran's original claim for service connection. 3. The Veteran has qualifying Southwest Asia theater service and it is presumed that he was exposed to fine, particulate matter during such service, as there is no affirmative evidence to establish that he was not. 4. The Veteran's currently diagnosed acute maxillary sinusitis and rhinitis, which manifested to at least some degree within 10 years of separation, is presumed to be associated with his Southwest Asia service. CONCLUSIONS OF LAW 1. The criteria for an effective date earlier than June 4, 1998 for the grant of service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400. 2. The criteria for service connection for acute maxillary sinusitis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.320. 3. The criteria for service connection for rhinitis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.320. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1981 to July 1984, from February 4, 1991 to September 30, 1991, and from July 3, 2000, to August 31, 2000. His decorations include a Southwest Asia Service Medal. These matters come to the Board of Veterans' Appeals (Board) from a June 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In November 2021, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. The record was held open to submit additional evidence. The Veteran submitted additional evidence directly to the Board in December 2021, along with a waiver of initial agency of original jurisdiction (AOJ) consideration of this evidence. Accordingly, the Board may consider evidence in the first instance. See 38 C.F.R. § 20.1304. Earlier Effective Date Claim 1. Entitlement to an effective date prior to June 4, 1998 for the grant of service connection for bilateral hearing loss is denied. The Veteran seeks an effective date earlier than June 4, 1998 for the grant of service connection for bilateral hearing loss. Specific argument in support of this appeal has not been submitted. The effective date of an evaluation and award of compensation on an original claim for compensation will be the day following separation from active duty service or the date entitlement arose if the claim is received within 1 year after separation from service; otherwise, the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a)-(b)(1); 38 C.F.R. § 3.400(b)(2). The Court of Appeals for Veterans Claims (Court) has explained that, in an original claim for service connection, the date entitlement arouse is governed by the date the claim is received, not the date of the medical evidence submitted to support a particular claim. See McGrath v. Gober, 14 Vet. App. 28 (2000). Where a prior unappealed decision becomes final and binding on a Veteran, the effective date of a subsequent award of service connection is the date of receipt of a reopened claim, not the date of receipt of the original claim. Sears v. Principi, 16 Vet. App. 244 (2002); Melton v. West, 13 Vet. App. 442 (2000). Under VA laws and regulations, a specific claim in the form prescribed by the VA must be filed in order for benefits to be paid or furnished to any individual under laws administered by the VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a). Any communication or action indicating intent to apply for one or more benefits under laws administered by the VA, and identifying the benefits sought, may be considered an informal claim. 38 C.F.R. § 3.155(a). The provisions of 38 U.S.C. § 5101(a) mandate that a claim must be filed in order for any type of benefit to accrue or be paid. See Jones v. West, 136 F.3d 1296, 1299 (Fed. Cir. 1998). Further, the mere presence of medical evidence in the record does not establish intent on the part of the Veteran to seek service connection for the benefit in question. Brannon v. West, 12 Vet. App. 32, 34-5 (1998). While the Board must interpret the Veteran's submissions broadly, the Board is not required to conjure up issues that were not raised by the Veteran. Id. The word "claim" includes a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p); Brannon v. West, 12 Vet. App. 32, 34-35 (1998); Servello v. Derwinski, 3 Vet. App. 196, 199 (1992). Any communication or action indicating intent to apply for one or more benefits under laws administered by VA from a Veteran may be considered to be an informal claim. Such an informal claim must identify the benefits sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. 38 C.F.R. § 3.155(a). To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). In this regard, as of such date, a claimant, or certain other individuals as specified in section 3.155(b), may indicate a claimant's intent to file a claim for benefits by submitting an intent to file a claim to VA. 38 C.F.R. § 3.155(b). An intent to file a claim must provide sufficient identifiable or biographical information to identify the claimant. Upon receipt of the intent to file a claim, VA will furnish the claimant with the appropriate application form prescribed by the Secretary. If VA receives a complete application form prescribed by the Secretary, as defined in 38 C.F.R. § 3.160(a), appropriate to the benefit sought within one year of receipt of the intent to file a claim, VA will consider the complete claim filed as of the date of the intent to file a claim was received. 38 C.F.R. § 3.155(b). Although a claimant need not identify the benefit sought "with specificity," see Servello v. Derwinski, 3 Vet. App. 196, 199-200 (1992), some intent on the part of the Veteran to seek benefits must be demonstrated. See Brannon v. West, 12 Vet. App. 32, 34-35 (1998). See also Talbert v. Brown, 7 Vet. App. 352, 356-7 (1995) (noting that while VA must interpret a claimant's submissions broadly, VA is not required to conjure up issues not raised by claimant). The United States Court of Appeals for the Federal Circuit has emphasized VA has a duty to fully and sympathetically develop a veteran's claim to its optimum. Hodge v. West, 155 F.3d 1356, 1362 (Fed. Cir. 1998). This duty requires VA to "determine all potential claims raised by the evidence, applying all relevant laws and regulations," Roberson v. West, 251 F.3d 1378, 1384 (Fed. Cir. 2001), and extends to giving a sympathetic reading to all pro se pleadings of record. Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004). In this regard, VA may not pay a benefit before a claim is made. 38 U.S.C. § 5101; Jones v. West, 136 F.3d 1296, 1299 (Fed. Cir. 1998) (stating that "[38 U.S.C.A. §] 5101 is a clause of general applicability and mandates that a claim must be filed in order for any type of benefits to... be paid under the laws administered by the Secretary.") The mere presence of medical evidence does not establish intent on the part of the Veteran to seek service connection for a disability. Lalonde v. West, 12 Vet. App. 377, 382 (1999); Brannon v. West, 12 Vet. App. 32, 35 (1998). More specifically, a medical examination report is only considered an informal claim for an increase in disability benefits if service connection has already been established for the disability. MacPhee v. Nicholson, 459 F.3d 1323, 1327 (Fed. Cir. 2006); see also 38 C.F.R. § 3.157(b)(1) (medical records can serve as informal claim "when such reports relate to examination or treatment of a disability for which service-connection has previously been established"). Likewise, the mere presence of a disability does not establish intent on the part of the Veteran to seek service connection for that condition. Crawford v. Brown, 5 Vet. App. 33, 35 (1995); KL v. Brown, 5 Vet. App. 205, 208 (1993). When all the evidence is assembled, the Secretary is then 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The basic facts in this case are not in dispute. The Veteran first filed a claim for service connection for hearing loss in June 1998. See claim, received by VA on June 4, 1988. The claim was denied in a September 1988 rating decision on the basis that the condition was not incurred in or caused by active service. See rating decision, September 29, 1988. The Veteran was informed of this decision in a September 1988 letter. The Veteran did not appeal that decision. The Veteran filed a petition to reopen the service connection for bilateral hearing loss in January 2018. See claim, received by VA on January 17, 2018. The claim was granted in a June 2018 rating decision with a rating of zero percent assigned, effective June 4, 1988, the date of the Veteran's original claim was received by VA See rating decision, July 19, 2019. The effective date of June 4, 1988, the date of the original claim for service connection was filed, was assigned as the Veteran's service treatment records were received after the issuance of the September 1988 rating decision. Ultimately, based on the laws and regulations previously cited, and after reviewing the totality of the evidence, the Board finds that an effective date prior to June 4, 1988 for the award of service connection for bilateral hearing loss is not warranted. There is simply no evidence to suggest that any claim for service connection for bilateral hearing loss was received prior to June 4, 1988. With no evidence that the VA received his claim for entitlement to service connection for bilateral hearing loss any earlier than June 4, 1988, the AOJ granted the claim for bilateral hearing loss effective June 4, 1988. To the extent that the Veteran may disagree with the effective date of June 4, 1988, the evidence of record provides no basis for an award of service connection prior to that date. See 38 C.F.R. §§ 3.1(p), 3.155(a). See also Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed. Cir. 2006) (holding that the plain language of the regulations requires a claimant to have intent to file a claim for VA benefits). While, under the provisions of 38 C.F.R. § 3.157(b)(1), the date of outpatient or hospital examination or the date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of a claim, the Court has held that this regulation only applies to a defined group of claims. See Sears v. Principi, 16 Vet. App. 244, 249 (2002) (section 3.157 applies to a defined group of claims, i.e., as to disability compensation, those claims for which a report of a medical examination or hospitalization is accepted as an informal claim for an increase of a service-connected rating where service connection has already been established). VA medical records cannot be accepted as an informal claim for disability where service connection has not been established. The mere presence of medical evidence does not establish intent on the part of the Veteran to seek service connection for a condition. See Brannon v. West, 12 Vet. App. 32, 35 (1998). Merely seeking treatment does not establish a claim, to include an informal claim, for service connection. The law and regulations surrounding the assignment of an effective date for an initial claim for service connection are clear and specific, namely the effective date is the date of receipt of the claim in a case where the receipt of claim comes after entitlement arose, and when the claim was received more than one year after discharge. See 38 C.F.R. § 3.400(r). There is no evidence of record to support any finding that the Veteran submitted a claim for service connection within one year of discharge, and there is also no evidence to suggest that any such claim was received earlier than June 4, 1998. Based on the analysis above and after reviewing the totality of the evidence, the Board finds that the effective date for the grants of service connection bilateral hearing loss has been appropriately assigned as the date the claim was received, i.e., June 4, 1988. See 38 C.F.R. § 3.400(r). The claim is therefore denied. 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). "To establish a right to compensation for a present disability, 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). The Veteran can provide competent reports of factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). In such cases, the Board is within its province to weigh that testimony and to make a determination as to whether the evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21. Vet. App. 303 (2007). Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature. Id. see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). 2. Entitlement to service connection for acute maxillary sinusitis is granted. 3. Entitlement to service connection for rhinitis is granted. The Veteran asserts that he developed breathing problems, including sinusitis and allergic rhinitis, as a result of exposure to environmental contaminants during his service in Southwest Asia. During the November 2021 Board hearing, the Veteran maintained that, as a result of being around the burn pits and oil fires, he developed breathing problems in service manifested by recurrent sinus infections, and he was prescribed an albuterol inhaler. The Veteran indicated that he also had nasal issues in service. He stated that he continued to experience breathing problems after service and was diagnosed with sinusitis in March 2001, within 10 years of his separation from active service. The Veteran also reported being diagnosed with rhinitis and sinusitis. See November 2021 Board hearing transcript at 5. Effective August 5, 2021, VA revised 38 C.F.R. § 3.320. These revisions apply to all claims received by VA on or after August 5, 2021, or that were pending before VA, the United States Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit on August 5, 2021. 86 Fed. Reg. 42724. As of August 5, 2021, under 38 C.F.R. § 3.320, if a veteran was exposed to particulate matter during active military service, certain chronic diseases, including asthma, shall be service-connected if it becomes manifest to any degree (including non-compensable) within 10 years from the date of separation from military service that includes a qualifying period of service as defined in 38 C.F.R. § 3.320(a)(4), except as provided in 38 C.F.R. § 3.320(b) or if there is affirmative evidence to establish that the veteran was not exposed to fine, particulate matter during that service. 38 C.F.R. § 3.320. In-service particulate matter exposure is presumed for veterans who served in Afghanistan, Syria, Djibouti, Uzbekistan, or the Southwest Asia theater of operations (Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations) during the Persian Gulf War, August 2, 1990, through a date Presidential proclamation or law will prescribe. 38 C.F.R. §§ 3.2(i), 3.317(e)(2), 3.320(a)(4). The Veteran' DD Form 214 demonstrates that he served from March 1991 to August 1991 in Southwest Asia. Accordingly, the Veteran is presumed to have been exposed to particulate matter during service. 38 C.F.R. § 3.320(a)(4). A May 2018 VA sinusitis Disability Benefits Questionnaire (DBQ) report indicates that the Veteran was diagnosed with acute maxillary sinusitis in March 2001. Post service VA and private treatment record, show that the Veteran has received treatment for recurring upper respiratory problems in 2001. In May 2001, the Veteran was seen with complaints of sinus congestion on the left side of the face with pressure, left ear pain and sore throat. The Veteran also reported a history of sinus problems in the past with removal of polyps in the sinuses four years ago. The assessment was sinusitis. A May 2018 VA treatment note indicates that the Veteran has had chronic rhinorrhea since 1991, Therefore, as sinusitis and rhinitis are chronic diseases presumed to be associated with exposure to fine, particulate matter, service connection is warranted on a presumptive basis as sinusitis and rhinitis were diagnosed within 10 years of the Veteran's separation from service as well as his service in Southwest Asia. The claims are granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND After examining the record, the Board concludes that further assistance to the Veteran is required in order to comply with the duty to assist as mandated by 38 U.S.C. § 5103A. The specific bases for remand are set forth below. 4. Entitlement to service connection for right leg fungus is remanded. 5. Entitlement to service connection for left leg fungus is remanded. 6. Entitlement to service connection for tinea pedis of the right foot is remanded. 7. Entitlement to service connection for tinea pedis of the left foot is remanded. The Veteran seeks service connection for right and left leg fungus which he maintains developed as a result of his exposure to environmental hazards during his period of active service. The Veteran contends that he suffers from tinea pedis and/or fungus on the legs as a result of his exposure to depleted uranium while on active-duty service. Service treatment records indicate that the Veteran was treated for a rash on the left leg in August 1982; the assessment was folliculitis. Subsequent service treatment records, including a September 1991 separation examination report, are silent for any further complaints, findings or treatment related to right or left leg fungus. He was treated for blisters on the right foot and unknown problem on the left foot in April 1991. In May 1991, he was again seen for complaints of blisters on both feet with scaling skin and painful blisters; he was diagnosed with tinea pedis. Another treatment note in May 1991 reflect a diagnosis of fungal infection. Subsequently, in June 1991, the Veteran was diagnosed with tinea pedis. In August 2000, the Veteran was evaluated for and diagnosed with athlete's foot (tinea pedis). Post service treatment records show that the Veteran was seen for skin conditions. A June 1998 VA progress note indicates that the Veteran complained of foot rash not healing; the assessment was while patchy areas on the left foot. A December 2001 clinic note reported a rash on both feet. The Veteran was seen in Podiatry clinic in January 2002, at which time it was noted that fungus of the skin on both feet were debrided. A December 2016 treatment note reflects a diagnosis of tinea pedis. During a DBQ examination for skin diseases in May 2018, it was noted that the Veteran has bilateral tinea pedis that he states started in 1990 during his time in Dessert Storm. The Veteran indicated that he has been dealing with episodes of breakouts throughout the years but does have times when he is symptoms free. He related that he first saw a podiatrist in 2016 when a biopsy was done and was positive for mold; he was prescribed Betamethasone. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed inservice injury, event or illness. The examiner explained that during service, the condition was acute only, and there was no chronicity of care. The examiner further stated that although the Veteran may have experienced tinea pedis during his time in Desert Storm, he has episodes or resolutions and reoccurrences that cannot be directly linked to the initial episode. The Board finds the examiner did not give any weight to the Veteran's competent statements that he has suffered from continued problems with his feet ever since his discharge from service. The Board also finds that this opinion is inadequate as it is supported only by a conclusory rationale; the examiner failed to explain why the current tinea pedis cannot be directly linked to service. As such, an additional VA examination is warranted. 8. Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with mood disorder, PTSD, and alcohol use disorder is remanded. The Veteran seeks service connection for a psychiatric disorder, which he asserts is related to service. At his Board hearing in November 2021, the Veteran reported witnessing horrific events while on active duty in the Persian Gulf. VA treatment records show that that the Veteran has been diagnosed with a psychiatric disorder, variously diagnosed as adjustment disorder with mixed disturbance of emotions and conduct, mood disorder and PTSD. Among the records is report of an intake evaluation dated in November 2016, at which time it was noted that the Veteran was being evaluated for sleep and anger problems as well as binge drinking. Following a mental status examination, the pertinent diagnoses were adjustment disorder with mixed disturbance of emotion and conduct, rule-out PTSD and rule-out bipolar disorder. It was noted that he was positive for symptoms of PTSD, mania and impulsivity. During a diagnostic intake examination in September 1999. At that time, it was noted that the Veteran was seen a few times in counseling in 1991; he was diagnosed with adjustment disorder, rule-out intermittent explosive disorder and rule-out substance abuse. The Veteran indicated that he served in the Persian Gulf; he had no active combat, but he saw dead bodies. Following a psychiatric evaluation, the diagnostic impression was major depression, single episode. At another mental health consultation in October 2020, the Veteran indicated that he was a platoon sergeant during service and was surrounded by dead bodies; he reported problems with sleeping since 1991. He reported having been in treatment for PTSD for six to seven months. A psychiatry note, dated in February 2021, indicates that the Veteran reported he was told that he was all cured back in 1992, but the dreams and the memories of when he was deployed still bothers him. He reported difficulty sleeping. It was noted that the Veteran was a convoy commander in Desert Storm and saw things that were not acceptable. When he returned stateside in 1992, he sought treatment for sleep issues and was told that he might have PTSD. He occasionally experiences traumatic memories when talking to fellow service members; he denied other PTSD criteria. The examiner stated that the Veteran does not appear to meet the criteria for a PTSD diagnosis; however, his history of labile mood, insomnia, intense bursts of goal-directed behavior, hyperverbal manner, and expansive mood suggest that he may meet the criteria for a bipolar-like mood disorder. VA is obliged to 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); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The requirement that the evidence "indicates" that the Veteran's disability "may" be associated with her service is a low threshold. Id. In light of the foregoing, the Board notes that there are current diagnoses of an acquired psychiatric disorder, as well as competent lay assertions as to the onset of symptoms in service and of a continuity of symptomatology in the years since service, along with assertions that the claimed disability may be associated with his service, but no competent opinion in this regard. Therefore, VA's duty to obtain an examination is triggered. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159; McLendon v. Nicholson, supra. 9. Entitlement to service connection for multiple joint pain, claimed as joint condition (nonspecific), including as due to an undiagnosed illness is remanded. The Veteran is also requesting service connection for current multiple joint pain, which he maintains may be related to his exposure to depleted uranium while on active duty in the Persian Gulf. At his Board hearing in November 2021, the Veteran maintained that while he was afforded a Gulf War examination, the AOJ only considered his feet and ankles; he stated that they failed to consider his back and knee problems. The Board finds the medical evidence of record insufficient to render a decision on this issue at this time and that a further examination and clarification opinion is needed. A review of the Veteran's service treatment records reveals treatment for muscle pain. In August 1982, the Veteran was treated for right hand pain. The Veteran was seen in February 1991 for complaints of an injury to the left knee during physical training; the assessment was left knee pain. In May 1991, he was diagnosed with stress fracture, left foot. Subsequently, in August 1991, the Veteran was seen for complaints of back pain as a result of a back injury 2 days prior to his visit; the assessment diagnosed with lumbar strain. In August 2000, the Veteran was evaluated for a right wrist injury. Post service treatment records, VA as well as private treatment reports, reflect a medical history of multiple joint pain. A November 2014 primary care note indicates that the Veteran was seen for complaints of pain in the elbows, hands, wrist and knees. The assessment was polyarthralgias. During a clinical visit in October 2016, it was noted that the Veteran had chronic joint pains, with stiffness in the morning for 30 minutes. No pertinent diagnosis was noted. A May 2018 treatment note also reported diagnoses of chronic joint pain, and low back pain. The Veteran was afforded VA examinations of the feet and ankles in May 2018, at which time he complained of bilateral foot pain. The pertinent diagnosis was multiple joint pains. The examiner indicated that they did not see a current pathology relevant to exposure while Southwest Asia in 2001 and related to bilateral foot and ankle pain. In the present case, the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War, and he has reported disability manifested by multiple joint pain. The Board cannot make a fully informed decision on the issue of entitlement to service connection for disability manifested by multiple joint pain because no VA examiner has opined as to the nature and etiology of the Veteran's claimed joint disability. Hence, he should be afforded an appropriate VA examination upon remand. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159; McLendon v. Nicholson, supra. 10. Entitlement to a compensable rating for bilateral hearing loss is remanded. The Veteran maintains that his bilateral hearing loss is more disabling than reflected by the noncompensable rating. A review of the claims file reflects that the Veteran was last afforded a VA examination in May 2018. That examination's findings equate to a noncompensable level of hearing loss for disability evaluation purposes. At his Board hearing in November 2021, the Veteran reported that his hearing has deteriorated since his last examination in 2018. The Veteran related that he has recently been issued hearing aids because he can't hear without them. The Court has held that when a Veteran alleges that his service-connected disability has worsened since he was examined previously, a new examination may be required to evaluate the current degree of impairment. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Given the potential of worsening, and because there is insufficient evidence upon which the Board can assess the current severity of the Veteran's bilateral hearing loss, the Board finds that a new examination, with findings responsive to applicable rating criteria, is needed to fully and fairly evaluate the Veteran's claim for a compensable rating. Caffrey v. Brown, 6 Vet. App. 377 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous."). The matters are REMANDED for the following actions: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A (b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for a VA examination to address the nature and etiology of his claimed any current disability manifested by multiple joint pain, leg fungus and/or tinea pedis. A complete copy of the claims file must be made available to the examiner, including a copy of this remand. The need for further in-person examination is left to the discretion of the examiner. After a thorough review of the medical and lay evidence of record is complete, the examiner should discuss the following: (A) The examiner should specifically state whether the Veteran's claimed multiple joint pain, leg fungus and/or tinea pedis is attributed to a known clinical diagnosis. (B) If any symptoms of multiple joint pain, leg fungus and/or tinea pedis have not been determined to be associated with a known clinical diagnosis, the examiner should indicate whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. The examiner should also indicate whether the condition is a medically unexplained chronic multisymptom illness (MUCMI), including whether the condition has an understood etiology or a partially understood etiology and whether the condition has an understood pathophysiology or partially understood pathophysiology in the context of the Veteran's unique circumstances. (C) If any symptoms of multiple joint pain, leg fungus and/or tinea pedis have been determined to be associated with a known clinical diagnosis, is it at least as likely as not (i.e., there is a 50 percent or greater probability) that such disorder is related to the Veteran's service? A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. A complete rationale for any opinion expressed must be provided. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 3. Following the receipt of outstanding records, arrange for the Veteran to undergo a VA mental disorders examination by an appropriate clinician to determine the nature and etiology of the Veteran's claimed acquired psychiatric disorder. The Veteran's entire electronic claims file, including a copy of this Remand, must be made available to and reviewed by the examiner in conjunction with the examination. All diagnostic testing deemed to be necessary by the examiner should be accomplished, and all clinical findings should be reported in detail. Based on examination of the Veteran and consideration of the entire record, the examiner should respond to the following questions: (A) Identify all current acquired psychiatric disorder(s) that have been present at any time since January 2018. (B) If PTSD is diagnosed, is at least as likely as not (50 percent or greater probability) the result of a verified in-service stressor or the fear of hostile military activity? It is noted that VA's definition of "fear of hostile military activity" means that a veteran experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. (C) Is it at least as likely as not (50 probability or greater) that the Veteran's current acquired psychiatric disorder(s) other than PTSD had its onset during service or is otherwise related to service? A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Following the receipt of outstanding records, schedule the Veteran for a VA examination to determine the current nature and severity of her service-connected bilateral hearing loss. The record, to include a copy of this Remand, should be made available to the examiner, and all indicated tests should be conducted. The examiner should identify the nature and severity of all current manifestations of the Veteran's service-connected bilateral hearing loss. A rationale for any opinion offered should be provided. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Suzie S. Gaston, 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.