Citation Nr: 1008253 Decision Date: 03/05/10 Archive Date: 03/11/10 DOCKET NO. 08-12 177 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an evaluation higher than 30 percent for service-connected posttraumatic stress disorder. 2. Entitlement to a compensable evaluation for service- connected bilateral hearing loss. 3. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected posttraumatic stress disorder. 4. Entitlement to service connection for gastroesophageal reflux disease, also claimed as hiatal hernia and irritable bowel syndrome, to include as secondary to service-connected posttraumatic stress disorder. 5. Entitlement to service connection for status post left total knee replacement, claimed as a bilateral knee disability. 6. Entitlement to service connection for right knee degenerative joint disease, claimed as a bilateral knee disability. 7. Entitlement to service connection for a spondylolytic defect at L5 with a grade 1 spondylolisthesis and status post provocative diskography due to a congenital defect in the lumbar spine, claimed as a back disability. 8. Entitlement to service connection for malignant melanoma in situ, excision; acute suppurative folliculitis; and actinic keratosis, claimed as a skin disability due to sun exposure. 9. Entitlement to an initial compensable evaluation for service-connected rhabdomyolysis/myoglobinuria with ongoing muscle strain. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD Andrew Dubinsky, Associate Counsel INTRODUCTION The Veteran had active service from July 1963 to June 1967. This matter arises before the Board of Veterans' Appeals (Board) from October 2007 and March 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The issues of entitlement to service connection for erectile dysfunction, to include as secondary to service-connected posttraumatic stress disorder; entitlement to service connection for gastroesophageal reflux disease, also claimed as hiatal hernia and irritable bowel syndrome, to include as secondary to service-connected posttraumatic stress disorder; entitlement to service connection for status post left total knee replacement and right knee degenerative joint disease, claimed as a bilateral knee disability; entitlement to service connection for a spondylolitic defect at L5 with a grade 1 spondylolisthesis and status post provocative diskography due to a congenital defect in the lumbar spine, claimed as a back disability; and entitlement to service connection for malignant melanoma in situ, acute suppurative folliculitis, and actinic keratosis, claimed as a skin disability due to sun exposure are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. The competent evidence of record shows that the Veteran's service-connected PTSD has been manifested by no more than occupational and social impairment with deficiencies in most areas due to such symptoms as suicidal ideations, inability to tolerate crowds or loud noises, restricted affect, nightmares, sleep impairment, and panic attacks. 2. The Veteran demonstrated a Level I hearing acuity in his right and left ears at an August 2007 VA audiological examination. 3. The competent evidence of record shows that the Veteran's service-connected rhabdomyolysis/myoglobinuria was not manifested by long term drug therapy, one to two hospitalizations per year and/or requiring intermittent intensive management, or requiring the wearing of absorbent materials which must be changed less than two times per day. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 70 percent for the Veteran's service-connected PTSD have been approximated for the entire appeal period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1- 4.14, 4.126, 4.130, Diagnostic Code 9411 (2009). 2. The criteria for a compensable rating for bilateral hearing loss have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.85, Diagnostic Code 6100 (2009). 3. The criteria for an initial compensable evaluation for the Veteran's service-connected rhabdomyolysis/myoglobinuria have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.115(a), 4.115(b), Diagnostic Code 7599- 7512 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information and any medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2009); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim, (2) that VA will seek to provide, and (3) that the claimant is expected to provide. The Board notes that the requirement of requesting that the claimant provide any evidence in his or her possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule revising 38 C.F.R. § 3.159(b) to rescind fourth element notice as required under Pelegrini II, effective May 30, 2008). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); but see Mayfield v. Nicholson, 19 Vet. App. 103, 128 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (when VCAA notice follows the initial unfavorable AOJ decision, remand and subsequent RO actions may "essentially cure [] the error in the timing of notice"). VCAA notice should also apprise the claimant of the criteria for assigning disability ratings and for award of an effective date. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In June 2007, July 2007, June 2008, and August 2008 correspondence, the RO generally advised the Veteran of what the evidence must show to establish an increased evaluation for his service-connected disorders, including specific notification of the rating criteria under the applicable diagnostic codes, and described the types of lay and medical evidence that the Veteran should submit in support of his claims. The RO also explained what evidence VA would obtain and make reasonable efforts to obtain on the Veteran's behalf in support of the claims. The VCAA notice letters also addressed the elements of degree of disability and effective date. As part of that notice, the RO told the Veteran that disability ratings usually range from zero to 100 percent depending on the disability involved and based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. In the present case, the Board notes that the Veteran was provided with adequate notice with respect to his increased rating claims by virtue of the aforementioned VCAA notice letters. Those documents informed the Veteran of the necessity of providing on his own or with VA assistance medical or lay evidence demonstrating a worsening or increase in severity of the disabilities and the effect that worsening has on the Veteran's employment. The letters also notified the Veteran that, should an increase in disability be found, a disability rating would be determined by applying relevant diagnostic code(s) and included examples of pertinent medical and lay evidence that the Veteran may submit or ask the Secretary to obtain relevant to establishing entitlement to increased compensation. Finally, the RO also provided the specific criteria required to establish entitlement to an increased rating found in Diagnostic Codes 7101, 7512, and 9411, as well as 38 C.F.R. § 4.115a for ratings of the genitourinary system-dysfunctions. Although the decision was subsequently modified, the Board notes that the United States Court of Appeals for Veterans Claims (Court) held in Vazquez-Flores v. Peake that certain notice elements were required for an increased rating claim. 22 Vet. App. 37 (2008); see Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). However, the Court drew a distinction between the notice requirements for a claim involving an initial disability rating and a claim for additional (increased) compensation of an already-service connected disability and only indicated that the notice requirements were relevant to claims for increased compensation. Id. As the issue of entitlement to a compensable evaluation for service-connected rhabdomyolysis/myoglobinuria arises from an initial disability rating, the Board finds that no discussion of VA's compliance with the notice elements outlined in Vazquez is necessary in this case. The Board further notes that the Veteran was provided with copies of the October 2007 and March 2008 rating decisions, March 2008 and August 2008 statements of the case, and the September 2008 and March 2009 supplemental statements of the case, which cumulatively included a discussion of the facts of the claims, notification of the bases of the decisions, a description of the pertinent laws and regulations, and a summary of the evidence considered to reach the decisions. Therefore, the Board concludes that the requirements of the notice provisions of the VCAA have been met, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Quartuccio, 16 Vet. App. at 187. To fulfill its statutory duty to assist, the RO afforded the Veteran with compensation and pension examinations in July 2007, August 2007 and March 2008; obtained supplemental medical opinions in October 2007 and February 2009; associated the Veteran's VA and private treatment records with the claims file to the extent possible; and reconstructed the Veteran's claims file to the extent possible, to include associating the Veteran's available service treatment records with the claims file. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are, collectively, more than adequate, as they were predicated on a full reading of the private and VA medical records in the Veteran's claims file. All examinations included the Veteran's subjective complaints about his disabilities and the objective findings needed to rate the disabilities. The Veteran has not made the RO or the Board aware of any other evidence relevant to this appeal that he or the VA needs to obtain. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claim. Accordingly, the Board will proceed with appellate review. Increased Ratings Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practically determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2009). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2009). Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2009). In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of the veteran's condition. Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the veteran's claim is to be considered. An appeal from the initial assignment of a disability rating, such as in this case, requires consideration of the entire time period involved and contemplates staged ratings where warranted. Fenderson v. West, 12 Vet. App. 119 (1999). Posttraumatic Stress Disorder (PTSD) In June 2007, the Veteran filed a claim for an increased rating for his service- connected PTSD because his condition had become worse, stating that he could not sleep, experienced nightmares, had trouble getting along with people, and suffered from spatial disorientation, moodiness, depression, and anger. The RO denied the Veteran's claim in an October 2007 rating decision. The Veteran disagreed with this decision and appealed to the Board. He claims that his symptoms warrant a disability rating higher than 30 percent. A 30 percent disability rating reflects evidence of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). In order for the Veteran to receive the next higher rating of 50 percent, the evidence must show that his PTSD symptoms approximate occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is the next possible disability rating above 50 percent. Such a rating is appropriate when PTSD symptoms approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Finally, a 100 percent disability rating is warranted when PTSD symptoms approximate total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. The amended regulations in 38 C.F.R. § 4.130 established a general rating formula for mental disorders. They assign ratings according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. The Board has reviewed the Veteran's complete claims file. Overall, the Board finds that the Veteran's symptomatology most closely approximated the criteria for a 70 percent disability rating for the entire appeal period. To be sure, the competent evidence of record begins with an August 2007 compensation and pension examination. At this point, he had low energy and expressed feeling of hopelessness and helplessness. He reported crying spells and marital problems. The Veteran further stated that he was agitated, had nightmares five nights a week, and felt nervous around his house when his grandchildren were visiting. He did not want to go out in public or be around other people. The Veteran also lacked a desire to pursue hobbies, such as mowing his lawn or restoring his tractor, or engage in social relationships at his church. The examiner noted a history of suicide attempts and that the Veteran admitted drinking a six pack of beer two to three days a week in addition to drinking every other day. On examination, the Veteran was restless but tense. He had an irritable attitude toward the examiner, a restricted affect, and an anxious, depressed mood. Although the Veteran's orientation was intact, he had an attention disturbance and a rambling thought process. The examiner described the Veteran's panic attacks and noted that he had several the week of the examination. Moreover, the Veteran told the examiner that he has had suicidal thoughts off and on for years but was not suicidal on the day of the examination. The Veteran experienced problems with activities of daily living, such as household chores, sports and exercise, and other recreational activities. The examination report indicates that he had recurrent and intrusive distressing recollections, dreams of his stressor events, and has made efforts to avoid thoughts, feelings, or conversations associated with his trauma. Furthermore, the examiner noted a markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, and a sense of a foreshortened future. The Veteran also displayed persistent symptoms of increased arousal, such as difficulty falling or staying asleep, irritability and outbursts of anger, difficulty concentrating, hypervigilance, and an exaggerated startle response. In summary, the examiner opined that the Veteran demonstrated moderate impairments in judgment, thinking, family relations, work, and mood. Two months later, the examiner added an addendum to his report to clarify that the Veteran also had a panic disorder that was separate and independent from his PTSD. In addition to this examination, the RO also associated the Veteran's VA treatment records related to his PTSD with the claims file. In December 2007, the Veteran presented with a depressed mood and denied suicidal ideations. A month later, in January 2008, the Veteran had a labile affect and reported suicidal ideations. Also in January 2008, the Veteran reported drinking about two to three beers a day for symptom reduction but stated that he had a positive relationship with his wife. However, his inability to tolerate even moderate crowds or loud noises created an additional stressor on his marriage, keeping him from going out with his wife as much as he would have liked. The Veteran also described a recent panic attack triggered by a trip to a museum and claimed that he sometimes heard whispers at night, felt his bed being kicked, or felt himself being shaken in his sleep when nobody was in the room with him. Another January 2008 treatment record indicated that the Veteran had a somewhat constricted affect. Then, in March 2008, the Veteran saw an increase in his problem solving skills and denied suicidal ideations. Shortly thereafter, however, the Veteran again began thinking about suicide in April 2008. The next month, even though the Veteran was at a lower risk for suicide, he admitted having more suicidal ideations. Finally, the Board notes that the Veteran's treatment providers have assigned him Global Assessment of Functioning (GAF) scores ranging from a low of 48 from January 2008 through April 2008 to a high of 55 during his August 2007 compensation and pension examination. In addition to those scores, the Veteran was assigned GAF scores of 50 in April 2008 and May 2008 treatment records. A GAF score ranging from 41 to 50 is assigned where there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job), and a GAF score of 51 to 60 is appropriate where there are moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers). Thus, the overall disability picture associated with the Veteran's PTSD as shown by the probative evidence of record most closely approximates the criteria associated with a 70 percent disability rating, representing occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Board notes that the Veteran suffered frequent suicidal ideations, panic attacks, impaired impulse control, difficulty adapting to stressful circumstances, and the inability to establish and maintain effective relationships. There is no evidence, however, that the Veteran's symptomatology approximated the criteria for a 100 percent disability rating as he did not demonstrate a gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, his occupation, or his name. The Board further notes that there is no evidence of record that the Veteran's claimed disability warrants a higher rating on an extraschedular basis. 38 C.F.R. § 3.321(b) (2009). Any limits on the Veteran's employability due to his disability have been contemplated in the currently assigned disability rating. The evidence does not reflect that the Veteran's disability has necessitated any frequent periods of hospitalization or caused marked interference with unemployment. Thus, the record does not show an exceptional or unusual disability picture not contemplated by the regular schedular standards that would warrant the assignment of an extraschedular rating. Since the application of the regular schedular standards is not rendered impracticable in this case, referral of this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) for consideration of the assignment of an extraschedular evaluation is not warranted. Bilateral Hearing Loss Hearing loss is evaluated under 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100, Tables VI, VIA, and VII of VA's rating schedule. The Rating Schedule provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, established by a state-licensed audiologist, including a controlled speech discrimination test (Maryland CNC), and based upon a combination of the percent of speech discrimination and the puretone threshold average, which is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz divided by four. 38 C.F.R. § 4.85 (2009). Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. Id. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a) (2009). When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. 38 C.F.R. § 4.86(b) (2009). In the present case, the Veteran seeks a higher evaluation for his service-connected bilateral hearing loss. The record reflects that the Veteran was granted service connection and assigned a noncompensable evaluation under Diagnostic Code 6100 in a December 2005 rating decision. The Board initially notes that the record contains no evidence of complete deafness in either ear. Indeed, at an August 2007 VA audiological examination, the Veteran exhibited puretone thresholds as follows: 15 decibels (dB) at 500 Hertz (Hz), 20 dB at 1000 Hz, 30 dB at 2000 Hz, 45 dB at 3000 Hz, and 60 dB at 4000 Hz with a puretone threshold average of 38.75 and a speech recognition score of 66 percent for the right ear and 15 dB at 500 Hz, 20 dB at 1000 Hz, 35 dB at 2000 Hz, 50 dB at 3000 Hz, and 60 dB at 4000 Hz with a pure tone threshold average of 41.25 and a speech recognition score of 58 percent for the left ear. However, the examiner cautioned that only the puretone threshold evaluation in the Veteran's audio examination should be considered because the Veteran's responses were always rhymed with the stimulus and presented with an inquisitive inflection in the Maryland CNC word list speech recognition test. After reinstructing the Veteran, the examiner obtained the same results. The examiner also stated that the Veteran would often replace lower-frequency consonants that he should easily hear with high-frequency consonants. As increasing stimulus intensity did not increase performance, the examiner concluded that only the puretone thresholds were reliable. The Board finds this explanation adequate, and will rate the Veteran's disability solely on the puretone threshold results. Under the guidelines set forth in 38 C.F.R. § 4.85, the August 2007 audiometric results reveal that the Veteran demonstrated a Level I hearing acuity in both ears. Thus, Table VII (Diagnostic Code 6100) provides a zero percent disability rating for the hearing impairment demonstrated at the examination for the entire appeal period. 38 C.F.R. § 4.85 (2009). Additionally, the Board notes that the audiometric test results from the audiological examinations did not show an exceptional pattern of hearing impairment for either ear. Furthermore, a review of relevant VA treatment records shows that there are no audiometric findings included therein showing a greater level of impairment than the aforementioned audiometric results. Based on the foregoing, the Board finds that the Veteran's hearing loss more closely approximates the criteria for the currently assigned noncompensable rating under Diagnostic Code 6100 throughout the entire appeal period, and entitlement to a compensable rating for bilateral hearing loss on a schedular basis is denied. In reaching this conclusion, the Board notes that under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the claim and that doctrine is not applicable. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Rhabdomyolysis/Myoglobinuria The Veteran filed a claim for rhabdomyolysis in June 2007. The RO originally denied the Veteran's claim in an October 2007 rating decision. The Veteran disagreed with this decision, and the RO granted service connection for rhabdomyolysis/myoglobinuria with ongoing muscle strain in March 2008 with a noncompensable disability rating effective June 5, 2007. The Veteran disagreed with the assigned disability rating and appealed to the Board. He claims that his symptoms warrant a compensable disability rating. Because rhabdomyolysis is not listed in the rating schedule, the RO rated the Veteran's disability under the analogous hyphenated Diagnostic Code 7599-7512. Diagnostic Code 7512 refers the rater to the criteria for voiding dysfunctions, which require "the wearing of absorbent materials which must be changed less than 2 times per day" for a compensable rating. 38 C.F.R. § 4.115a (2009). The Board notes that the RO also considered the rating criteria for urinary tract infections when rating the Veteran's disability. In order to receive a compensable evaluation under the rating criteria for urinary tract infections, the record must show "long- term drug therapy, 1-2 hospitalizations per year and/or requiring intermittent intensive management." The Veteran was afforded a muscles examination in conjunction with this claim in March 2008. The examiner noted that the Veteran's only hospital treatment for this disability was at Lackland Air Force Base in the 1960s. He also found that the Veteran did not have a muscle that had been injured, destroyed, or traversed; had no intermuscular scarring; and had normal muscle function in terms of comfort, endurance, and strength sufficient to perform activities of daily living. Furthermore, there were no residuals of nerve damage, tendon damage, or bone damage, as well as no findings of muscle herniation, loss of deep fascia or muscle substance, or limitation of any joint motion by the muscle disease or injury. The examiner found that the Veteran had muscle aches associated with his disability that resulted in some moderate effects on the Veteran's daily activities, such as chores, shopping, recreation, and travel, while preventing his participation in sports and exercise. The Veteran reported that since his hospitalization in the 1960s, he has had dark colored urine and generalized muscle pains on days following exertion. Although the examiner predicted that the Veteran will lose strength and experience functional impairment because he will avoid some activities, the report indicates that no muscles were injured or destroyed and that the Veteran was not receiving treatment for his disability. On the day of the examination, the Veteran's muscle strength was good, his vital signs were normal, and no specific joints were involved. Because the Veteran complained of dark colored urine after exertion, the examiner conducted a urine analysis and told the Veteran to perform a strenuous activity before returning the next day for a second urine analysis. There was some blood in the Veteran's urine on the day of the examination, but the second urine analysis was negative for myoglobin. Nevertheless, the examiner diagnosed the Veteran with myoglobinuria/rhabdomyolysis with ongoing muscle strain, generalized. The Board also recognizes that the Veteran underwent a genitourinary examination related to his erectile dysfunction and gastroesophageal reflux disease in July 2007 that resulted in some evidence relevant to his claim for rhabdomyolysis. This examination report indicated that there was no history of trauma to the genitourinary system or urethral discharge. The Veteran reported voiding every one to two hours during the day and once per night and claimed to experience urinary leakage but no urinary tract infections or stones or renal dysfunction or failure. Furthermore, the Veteran denied urinary incontinence. Thus, considering the competent evidence of record, the Board finds no evidence of long-term drug therapy, one to two hospitalizations per year and/or requiring intermittent intensive management, or the need to wear absorbent materials. Therefore, the Board finds that the Veteran is not entitled to a compensable disability rating under either the rating criteria for urinary tract infections or voiding dysfunctions. The Veteran contended in his April 2008 notice of disagreement that he should also be considered for an increased rating under Diagnostic Codes 5025 or 6354. However, the Board notes that he does not require constant medication to control his disability as required under Diagnostic Code 5025 and has not had any periods of incapacitation, defined as requiring bed rest and treatment by a physician, as required under Diagnostic Code 6354. Therefore, neither of these diagnostic codes warrant a compensable evaluation. The Board further notes that there is no evidence of record that the Veteran's claimed disability warrants a higher rating on an extraschedular basis. 38 C.F.R. § 3.321(b) (2009). Any limits on the Veteran's employability due to his disability have been contemplated in the currently assigned disability rating. The evidence does not reflect that the Veteran's disability has necessitated any frequent periods of hospitalization or caused marked interference with employment. Thus, the record does not show an exceptional or unusual disability picture not contemplated by the regular schedular standards that would warrant the assignment of an extraschedular rating. Since the application of the regular schedular standards is not rendered impracticable in this case, referral of this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) for consideration of the assignment of an extraschedular evaluation is not warranted. In reaching this conclusion, the Board notes that under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the claim and that doctrine is not applicable. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER 1. Entitlement to an evaluation of 70 percent for service- connected posttraumatic stress disorder is granted for the entire appeal period, subject to the laws and regulations governing the payment of monetary benefits. 2. Entitlement to a compensable evaluation for service- connected bilateral hearing loss is denied. 3. Entitlement to an initial compensable evaluation for service-connected rhabdomyolysis/myoglobinuria with ongoing muscle strain is denied. REMAND After careful review of the record, the Board finds that a remand for additional development is necessary before proceeding to evaluate the merits of the Veteran's claims of entitlement to service connection for erectile dysfunction, to include as secondary to service-connected posttraumatic stress disorder; gastroesophageal reflux disease, also claimed as hiatal hernia and irritable bowel syndrome, to include as secondary to service-connected posttraumatic stress disorder; knee disabilities; a back disability; and a skin disability. The record reflects that the Veteran underwent a VA compensation and pension examination conducted by a physician assistant, B.S.R., in July 2007 for his erectile dysfunction and gastroesophageal reflux disease. B.S.R. wrote an addendum to this opinion in February 2009. However, B.S.R.'s opinion only concluded that the Veteran's disabilities were less likely than not related to his service-connected PTSD and did not give an opinion as to whether or not they were otherwise related to his period of active military service. The Board notes that the Veteran filed claims for both disabilities on a direct service connection theory as well as on a theory that they were secondary to his service-connected PTSD. Therefore, the examiner's opinion is inadequate as it failed to provide an opinion on the Veteran's direct service connection theory, and a supplemental opinion is required with respect to the Veteran's claimed erectile dysfunction and gastroesophageal reflux disease before those claims can be adjudicated. As for the Veteran's claims of entitlement to service connection for his knee disabilities, back disability, and skin disability, VA must provide a compensation and pension examination to a Veteran when the information and evidence of record (1) contains competent lay or medical evidence of a currently diagnosed disability; (2) establishes that the Veteran suffered an event, injury, or disease in service, or has a disease or symptoms of a disease listed in 38 C.F.R §§ 3.309, 3.313, 3.316, and 3.317 manifesting during the applicable presumptive period if the Veteran has the required service to trigger the presumption; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service. 38 C.F.R. § 3.159(c)(4)(i) (2009). The Veteran has presented competent evidence that he has current knee, back, and skin disabilities. In addition, in light of the fact that some service treatment records may be absent from the claims file, the Board finds that the requirements of 38 C.F.R. § 3.159 have been met and that the Veteran should be afforded with compensation and pension examinations for his disabilities. Accordingly, the case is REMANDED for the following action: 1. A supplemental opinion should be obtained from the July 2007 VA examiner, B.S.R., with respect to the Veteran's claimed erectile dysfunction and gastroesophageal reflux disease. B.S.R. should specifically state whether or not the Veteran's erectile dysfunction and gastroesophageal reflux disease are at least as likely as not (i.e., probability of 50 percent) related to his period of active military service. Please send the claims folder to B.S.R. for the supplemental opinion. If B.S.R. is not available, please obtain the requested supplemental opinion from another appropriate clinician. The clinician should provide an opinion based on review of the claims folder on whether or not it is at least as likely as not (i.e., probability of 50 percent) that the Veteran's erectile dysfunction and gastroesophageal reflux disease are related to his period of active military service. 2. The Veteran should be afforded with an appropriate examination(s) to determine the nature and etiology of any current knee, back, and skin disabilities he may have. The claims file and a copy of this remand must be made available to and reviewed by the examiner(s) prior to the requested examination(s). The examiner(s) should indicate in the report that the claims file was reviewed. All necessary tests should be conducted, and the examiner(s) should review the results of any testing prior to completion of the report(s). The examiner(s) should specifically state what knee, back, and skin disabilities the Veteran is diagnosed with, if any, and whether or not those knee, back, and skin disabilities are at least as likely as not (i.e., probability of 50 percent) etiologically related to the Veteran's period of active military service. If the examiner(s) is unable to give such an opinion without resorting to mere speculation, the examiner(s) should state so and give the reasons why he or she cannot give such an opinion. The examiner(s) must provide a comprehensive report(s) including complete rationales for all conclusions reached. 3. Thereafter, the Veteran's claims should be readjudicated. If any benefit sought on appeal remains denied, the Veteran should be provided with a supplemental statement of the case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issue. An appropriate period of time should be allowed for response by the Veteran and his representative. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. 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 (1999). These claims 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.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ John E. Ormond, Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs