Citation Nr: 0024041 Decision Date: 09/11/00 Archive Date: 09/21/00 DOCKET NO. 99-08 556A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for hearing loss. 2. Entitlement to service connection for asbestosis. 3. Entitlement to an initial disability rating higher than 10 percent for residuals of prostate cancer. 4. Entitlement to an initial compensable disability rating for impotence. WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD M. L. Kane, Associate Counsel INTRODUCTION The veteran had active military service from May 1958 to October 1961 and from July 1965 to June 1969, with additional unverified periods of inactive service until approximately 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 1999 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, which denied service connection for hearing loss and asbestosis; granted service connection for residuals of prostate cancer, with assignment of a 10 percent disability rating; and granted service connection for impotence, with assignment of a zero percent (noncompensable) disability rating. The Board notes that the April 1999 rating decision did award the veteran special monthly compensation based on loss of use of a creative organ. A September 1999 rating decision granted service connection for an adjustment disorder with depressed mood, with assignment of a 10 percent disability rating. The veteran filed a notice of disagreement in November 1999, and a statement of the case was issued in January 2000. As the veteran has not, as of this date, perfected an appeal to the Board as to the assignment of a 10 percent disability rating for his psychiatric disorder, the Board does not have jurisdiction to consider this issue. See 38 C.F.R. §§ 20.200, 20.202, and 20.302(b) (1999). As discussed below, the claim for service connection for asbestosis is being REMANDED because it is well grounded and additional development is needed. FINDINGS OF FACT 1. The veteran does not currently have a hearing loss disability in the right ear as defined by applicable law, and the claim for service connection for right ear hearing loss is not plausible. 2. There is no competent medical evidence showing the development of hearing loss during the veteran's active service or within the year after his separation from service. 3. There is no competent medical evidence showing that the current decreased hearing acuity in the left ear is related to disease or injury incurred during service, and the claim for service connection for left ear hearing loss is not plausible. 4. The medical evidence shows a current diagnosis of asbestosis. The veteran has submitted competent lay evidence that he was exposed to asbestos during service, and the diagnosis of asbestosis was based, at least in part, on such a history. 5. The claim of entitlement to service connection for asbestosis plausible. 6. The veteran's claims for higher ratings for residuals of prostate cancer and impotence are plausible, and the RO has obtained sufficient evidence for correct disposition of these claims. 7. The veteran completed treatment for his prostate cancer in 1996, with no clinical evidence of recurrence or metastasis. The residuals of the prostatectomy are manifested by "mild" urinary frequency consisting of nocturia approximately 1-2 times per night, slight "stress" incontinence, and occasional leakage. 8. The veteran has sexual impotence without deformity of the penis. CONCLUSIONS OF LAW 1. The claim for service connection for hearing loss is not well grounded, and there is no statutory duty to assist the veteran in developing facts pertinent to this claim. 38 U.S.C.A. § 5107 (West 1991). 2. The claim for service connection for asbestosis is well grounded, but VA has not satisfied its statutory duty to assist the veteran in developing facts pertinent to this claim. 38 U.S.C.A. §§ 5103 and 5107(a) (West 1991); 38 C.F.R. § 3.103 (1999). 3. The veteran's claims for higher disability ratings for residuals of prostate cancer and impotence are well grounded, and VA has satisfied its duty to assist him in developing facts pertinent to these claims. 38 U.S.C.A. §§ 5103 and 5107(a) (West 1991); 38 C.F.R. § 3.103 (1999). 4. The criteria for an initial disability evaluation in excess of 10 percent for residuals of prostate cancer have not been met. 38 U.S.C.A. §§ 1155 and 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, and 4.115a and b, Diagnostic Code 7528 (1999). 5. The criteria for an initial compensable disability rating for sexual impotence are not met. 38 U.S.C.A. §§ 1155 and 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.31 and 4.115b, Diagnostic Code 7522 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all the evidence of record, which consists of the veteran's service medical records dated from 1958 to 1988; his contentions, including those raised at a personal hearing in 1999; a statement from his wife, as well as her testimony provided at the 1999 hearing; VA medical records for outpatient treatment in 1999; reports of VA examinations conducted in 1998 and 1999; and private medical records from Michael May, M.D., Gardner Fletcher, M.D., Hattiesburg Clinic, Dianon Systems, Inc., and Forrest General Hospital. The evidence pertinent to each issue on appeal is discussed below. A. Legal criteria concerning service connection Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110 and 1131; 38 C.F.R. § 3.303(a). It is the responsibility of a person seeking entitlement to service connection to present a well- grounded claim. 38 U.S.C.A. § 5107 (West 1991). A well-grounded claim is a "plausible claim, one which is meritorious on its own or capable of substantiation." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A claim for service connection requires three elements to be well grounded. It requires competent (medical) evidence of a current disability; competent (lay or medical) evidence of incurrence or aggravation of disease or injury in service; and competent (medical) evidence of a nexus between the in- service injury or disease and the current disability. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997), cert. denied, sub nom. Epps v. West, 118 S.Ct. 2348 (1998); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); aff'd 78 F.3d 604 (Fed.Cir. 1996) (table). Generally, the Board should consider only the evidence that is or may be favorable to the claim in deciding whether it is well grounded. See Arms v. West, 12 Vet. App. 188, 195 (1999) (noting that generally "only the evidence in support of the claim is to be considered and generally a presumption of credibility attaches to that evidence in order to decide whether or not any VA claimant has sustained the claimant's burden of submitting a well-grounded claim under section 5107(a)") (emphasis in original). 1. Hearing loss Service connection may also be established for a current disability on the basis of a presumption under the law that certain chronic diseases manifesting themselves to a certain degree within a legally-established period of time after service must have had their onset in service. 38 U.S.C.A. §§ 1110, 1112, 1131 and 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307 and 3.309(a). Service connection for sensorineural hearing loss may be established based on a legal presumption by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307 and 3.309; see Under Secretary for Health letter (October 4, 1995) (It is appropriate for VA to consider sensorineural hearing loss as an organic disease of the nervous system and, therefore, a presumptive disability.) With respect to hearing loss, VA has specifically defined what is meant by a "disability" for the purposes of service connection. 38 C.F.R. § 3.385. ("[I]mpaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent."). The requirements for service connection for hearing loss as defined in 38 C.F.R. § 3.385 need not be shown by the results of audiometric testing during a claimant's period of active military service in order for service connection to be granted. 38 C.F.R. § 3.385 does not prevent a claimant from establishing service connection on the basis of post-service evidence of hearing loss related to service when there were no audiometric scores reported at separation from service. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). This regulation also does not necessarily preclude service connection for hearing loss that first meets the regulation's requirements after service. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Thus, a claimant who seeks to establish service connection for a current hearing loss disability must show, as is required in a claim for service connection for any disability, that a current hearing disability is the result of an injury or disease incurred in service, the determination of which depends on a review of all the evidence of record including that pertinent to service. 38 U.S.C.A. § 1110; C.F.R. §§ 3.303 and 3.304; Hensley, 5 Vet. App. at 159-60. The veteran's service medical records covering his period of active duty show no complaints of decreased hearing acuity, and the veteran's hearing was reported as normal (15/15 bilaterally for whispered and spoken voice) on the 1961 and 1969 separation examinations. On Reports of Medical History completed in 1973, 1974, 1975, 1976, 1978, 1980, 1983, 1984, 1986, 1987, and 1988, he denied having any difficulty with hearing loss. On the Report of Medical History completed in 1981, he indicated that he did not know if he had hearing loss. On the Reports of Medical Examinations conducted in 1973, 1975, 1976, 1977, and 1978, the veteran's hearing was reported as normal (15/15 bilaterally for whispered and/or spoken voice). Audiograms conducted in 1974, 1986, and 1987 showed essentially normal findings through 4000 Hertz, see Hensley, 5 Vet. App. at 157 (threshold for normal hearing is from zero to 20 decibels), with the exception of findings of 25 decibels at 4000 Hertz for the left ear. Upon VA examination in December 1998, the veteran reported "longstanding" hearing difficulties and a history of noise exposure during service. The authorized audiological evaluation showed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 5 15 35 LEFT 15 10 10 45 45 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 98 percent in the left ear. The diagnosis was mild sensorineural "dip" in the right ear and mild sensorineural hearing loss in the left ear. In this case, the veteran is not entitled to presumptive service connection for sensorineural hearing loss. A diagnosis of sensorineural hearing loss was not rendered until many years after service (at the earliest, 1998), and there is no evidence showing that this disorder was manifested within the first post-service year. In fact, the medical evidence from his many years of inactive military service conclusively demonstrates that hearing loss was not present up to and including 1988. The veteran is not entitled to direct service connection for hearing loss in the right ear because the medical evidence does not show that he has a current disability. None of the auditory thresholds between 500 and 4000 Hertz for the right ear was 40 decibels or greater. Only one of the auditory thresholds between 500 and 4000 Hertz for the right ear was greater than 26 decibels, and his speech recognition score on the Maryland CNC Test was 100 percent for the right ear. Therefore, the veteran does not have a current hearing loss disability in the right ear according to VA regulations. Since there is no competent medical evidence of a current disability, the claim for service connection for right ear hearing loss is not plausible. Although the veteran does meet the legal requirements for hearing loss in the left ear, there is no medical nexus evidence to associate the current decreased hearing acuity on the left with a disease or injury during service. Incurrence of chronic left ear hearing loss during service is not shown. A diagnosis of left ear hearing loss was not rendered during active service. Reports of service separation examinations, as well as those pertaining to the veteran's inactive service examinations, showed essentially normal hearing acuity for the left ear. There is no post-service medical evidence showing complaints or diagnosis of decreased hearing acuity involving the left ear until 1998, which was 39 years after the veteran's separation from active service and approximately 10 years after his final separation from inactive service. There is no competent evidence showing that he had any difficulties with his hearing in the left ear prior to 1998. More importantly, at no time has a medical professional stated that the veteran's current decreased hearing acuity on the left is in any manner related to his military service or that it began during service. Therefore, the Board concludes that this claim is not plausible. The only evidence indicating that the veteran's claimed hearing loss is related to his military service consists of his current statements. However, he cannot meet his initial burden under 38 U.S.C.A. § 5107(a) by simply presenting his own lay opinion. He does not have the medical expertise to render a probative opinion as to medical diagnosis or causation. See Edenfield v. Brown, 8 Vet. App. 384, 388 (1995); Robinette v. Brown, 8 Vet. App. 69, 74 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Until the veteran establishes a well-grounded claim, VA has no duty to assist him in developing facts pertinent to the claim, including providing him additional medical examinations at VA expense. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.326(a); see Morton v. West, 12 Vet. App. 477 (1999) (VA cannot assist a claimant in developing a claim that is not well grounded); Grivois v. Brown, 6 Vet. App. 136, 139-40 (1994) (noting that "implausible claims should not consume the limited resources of the VA and force into even greater backlog and delay those claims which . . . require adjudication"). Nonetheless, where a claim is not well grounded, it is incomplete, and VA is obliged under 38 U.S.C.A. § 5103(a) to advise the claimant of the evidence needed to complete his application for benefits. Robinette v. Brown, 8 Vet. App. 69, 77-80 (1995). The RO notified the veteran in the January 2000 supplemental statement of the case that the evidence did not demonstrate a plausible relationship between any current hearing loss and any disease or injury during service. The Board views that information, in conjunction with the information contained in this decision, as informing the veteran of the type of evidence needed, thus satisfying Robinette. See also Epps v. Brown, 9 Vet. App. 341, 344-45 (1996), aff'd Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). VA has no outstanding or further duty to inform the veteran of the necessity to submit certain evidence to complete his application for VA benefits as he has not referred to any specific piece of evidence that is missing. See 38 U.S.C.A. § 5103(a). He has not alleged that any medical records exist that would tend to show that he has hearing loss that is somehow related to his military service. The presentation of a well-grounded claim is a threshold issue. Since the veteran has failed to present competent medical evidence that his claim for service connection for hearing loss is plausible, the claim must be denied as not well grounded. Dean v. Brown, 8 Vet. App. 449 (1995); Boeck v. Brown, 6 Vet. App. 14, 17 (1993). There is no duty to assist further in the development of this claim, because such additional development would be futile. See Murphy, 1 Vet. App. 78. 2. Asbestosis The veteran contends that he has asbestosis as a result of asbestos exposure during service. His service record (DD- 214) shows that he was a Boiler Operator from 1958 to 1961, and he maintains that asbestos was extensively used in that environment. His active and inactive service medical records show no respiratory complaints. A chest x-ray conducted in June 1985 at Methodist Hospital showed early signs of interstitial pulmonary fibrosis. In June 1999, a chest x-ray showed increased interstitial markings in the lung bases with multiple small nodules. Dr. Fletcher concluded that these findings were consistent with asbestosis. In July 1999, computerized tomography (CT) scan of the chest showed increased interstitial markings and small punctate nodules, which Dr. Fletcher again concluded was consistent with asbestosis. In contrast, VA examination in December 1998, which also included chest x-ray and CT scan, yielded no evidence of asbestosis. There is no statute specifically dealing with asbestos and service connection for asbestos-related diseases, nor has the Secretary promulgated any specific regulations. However, in 1988, VA issued a circular on asbestos-related diseases that provided guidelines for considering asbestos compensation claims. See Department of Veterans Benefits, Veterans' Administration, DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988). The information and instructions contained in the DVB Circular have since been included in VA Adjudication Procedure Manual, M21-1, part VI, para. 7.21 (January 31, 1997) (hereinafter "M21-1"). Also, a recent opinion by VA's General Counsel discussed the provisions of M21-1 regarding asbestos claims and, in part, also concluded that medical nexus evidence is needed to establish a well- grounded claim based on alleged in-service asbestos exposure. VAOPGCPREC 4-00. VA must analyze the veteran's claim of entitlement to service connection for asbestos-related disease under these administrative protocols using the following criteria. Ennis v. Brown, 4 Vet. App. 523, 527 (1993); McGinty v. Brown, 4 Vet. App. 428, 432 (1993). The latency period for asbestos- related diseases varies from 10 to 45 or more years between first exposure and development of disease. M21-1, Part VI, 7.21(b)(2), p. 7-IV-3 (January 31, 1997). An asbestos- related disease can develop from brief exposure to asbestos. Id. The veteran's contentions regarding in-service exposure to asbestos are plausible. His service records indicate that he was a Boiler Operator from 1958 to 1961, and he served aboard Naval ships. There is no evidence contradicting the veteran's assertions of exposure, and his assertions are consistent with his service duty. The routine duties of a Boiler Operator would have exposed the veteran to asbestos if it were present on any of the ships he served on. Based on this evidence, exposure to asbestos during service is established. See McGinty v. Brown, 4 Vet. App. 428 (1993) (held that the veteran's testimony as to the cause of his disease was not competent evidence of causation because the determination of the cause of a disease is a medical matter; however, the veteran was competent to testify as to the facts of his asbestos exposure, i.e., wearing asbestos gloves while performing his duties as a "hot caseman" in the Navy). Dr. Fletcher referenced the veteran's history of asbestos exposure during service and rendered diagnoses of asbestosis. Although Dr. Fletcher did not expressly indicate that the veteran's asbestos-related disease resulted from in-service exposure, as discussed below, the diagnosis based on a history of asbestos exposure during service included, by inference, a conclusion that the diagnosed disorder was related to such exposure. In other words, the diagnosis of asbestosis was based, at least in part, on the reported history of exposure to asbestos during service. Assuming the credibility of this evidence, the claim must be said to be plausible, and therefore well grounded. See, e.g., Alemany v. Brown, 9 Vet. App. 518, 519 (1996) ("possible" link enough to well grounded claim); cf. Hodges v. West, 13 Vet. App. 287, 291 (2000) (because the only trauma shown in the record was the trauma the veteran received during service, then the physician's diagnosis of a post-traumatic condition is sufficient evidence of nexus). Although there is also medical evidence indicating that the veteran does not have asbestosis, such evidence is not for consideration at this stage of adjudication, but, rather, will be considered when the claim is decided on the merits. The Board concludes that this is not the type of well- grounded claim that is meritorious on its own, but rather one that may be capable of substantiation with further development of the medical evidence on remand. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The record does not contain sufficient evidence to decide this claim fairly, as discussed more fully below. Accordingly, further assistance is required to comply with the duty to assist mandated by 38 U.S.C.A. §§ 5103 and 5107. The necessary development will be discussed in the REMAND section below. B. Legal criteria concerning evaluation of a service-connected disability As indicated earlier, the first responsibility of a claimant is to present a well-grounded claim. 38 U.S.C.A. § 5107(a). In this case, the veteran perfected his appeal as to the initial grants of service connection and original assignment of disability ratings for residuals of prostate cancer and impotence. His claims continue to be well grounded as long as the rating schedule provides a higher rating for the service-connected conditions. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). VA has a duty to assist the veteran in the development of facts pertinent to his claims. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.103. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the RO provided the veteran an appropriate VA examination in 1998. There is no medical evidence indicating that there has been a change in the severity of the veteran's prostate or penile disorders since he was last examined. There is also no indication that VA or private treatment records exist that have not been obtained. There is sufficient evidence to rate the service-connected disabilities fairly. Therefore, the duty to assist the veteran has been satisfied. The veteran has disagreed with the original disability ratings assigned for his residuals of prostate cancer and impotence. There is a distinction between a claim based on disagreement with the original rating awarded and a claim for an increased rating. Fenderson v. West, 12 Vet. App. 119 (1999). The Statement of the Case issued to the veteran in May 1999 shows that the RO considered all the evidence of record in assigning the original disability ratings for residuals of prostate cancer and impotence. The RO did not limit its consideration to only the recent medical evidence of record, and did not therefore violate the principle of Fenderson. The veteran has been provided appropriate notice of the pertinent laws and regulations and has had his claims of disagreement with the original ratings properly considered based on all the evidence of record. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. Evaluation of a service-connected disorder requires a review of the veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1 and 4.2. Since the veteran appealed the initial rating assigned for his back disorder, the entire body of evidence is for equal consideration. Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999). It is also necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to the veteran's disability, 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. 1. Residuals of prostate cancer In 1996, the veteran underwent a radical prostatectomy for prostate cancer. He has been granted service connection for residuals of the prostate cancer based on a presumption that he was exposed to Agent Orange while serving in Vietnam. See 38 C.F.R. § 3.309(e). Associated with the claims file are his medical records from Dr. Fry, who treated him for the prostate cancer and has continued to treat him for any residuals, which are dated from 1994 to 1999. Also, the veteran underwent a VA examination in 1998. The veteran is currently evaluated under 38 C.F.R. § 4.115b, Diagnostic Code 7528, as 10 percent disabled. Diagnostic Code 7528 pertains to malignant neoplasms of the genitourinary system and provides a 100 percent evaluation when such a condition is active or being treated. Following the cessation of surgical, x-ray, antineoplastic, chemotherapy, or other therapeutic procedure, the 100 percent rating shall continue with a mandatory VA examination at the expiration of six months. In this case, the veteran did not apply for service connection for prostate cancer until long after surgery and cessation of treatment for the disease. Therefore, he was not eligible for assignment of a 100 percent rating for any period of time under Diagnostic Code 7528. See 38 C.F.R. § 3.400(b)(2)(ii) (disability compensation pursuant to a grant of presumptive service connection will be awarded from date of receipt of claim if claim filed more than one year after separation from service). Under Diagnostic Code 7528, where there has been no local reoccurrence or metastasis of the cancer following the cessation of treatment, then the disability is rated on the residuals of voiding dysfunction or renal dysfunction, whichever is predominant. Diseases of the genitourinary system generally result in disabilities related to renal or voiding dysfunctions, infections, or a combination of these. Review of the medical evidence in this case reveals no evidence of reoccurrence or metastasis of the veteran's prostate cancer subsequent to his prostatectomy. Hence, his post-operative residuals of the prostate cancer are evaluated under either voiding dysfunction or renal dysfunction, whichever is predominant, under 38 C.F.R. § 4.115a (ratings of the genitourinary system-dysfunctions). In this case, the residuals of prostate cancer are most appropriately evaluated in terms of voiding dysfunction, as there is no medical evidence of renal dysfunction. Voiding dysfunction is rated under the three subcategories of urine leakage, urinary frequency, and obstructed voiding. In this case, there is no medical evidence of symptomatology associated with obstructed voiding (i.e., urinary retention requiring intermittent or continuous catheterization, etc.), and the veteran has not complained of symptoms such as hesitancy, slow or weak stream, or decreased force of stream. In fact, Dr. Fry's records indicate that the veteran is able to adequately empty his bladder, and his stream is also adequate. No medical professional has stated that the veteran has obstructed voiding, and there is no medical evidence showing any urinary tract infections. Therefore, the rating assigned to the veteran's residuals of prostate cancer will be based on the severity of voiding dysfunction in terms of urine leakage or urinary frequency, which are the veteran's only complaints. Ratings for urine leakage range from 20 to 60 percent. A 60 percent rating contemplates continual urine leakage, post- surgical urinary diversion, urinary incontinence, or stress incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. A 40 percent rating contemplates leakage requiring the wearing of absorbent materials that must be changed 2 to 4 times per day. A 20 percent rating contemplates leakage requiring the wearing of absorbent materials that must be changed less than 2 times per day. Ratings for urinary frequency range from 10 to 40 percent. A 40 percent rating contemplates daytime voiding interval less than 1 hour, or awakening to void 5 or more times per night. A 20 percent rating contemplates daytime voiding interval between 1 and 2 hours, or awakening to void 3 to 4 times per night. A 10 percent rating contemplates daytime voiding interval between 2 and 3 hours, or awakening to void 2 times per night. Reviewing the pertinent evidence of record, the Board concludes that the veteran's residuals of prostate cancer are most appropriately evaluated as 10 percent disabling on the basis of urinary frequency, as defined by 38 C.F.R. § 4.115a. To summarize his complaints, as shown by the medical records from Dr. Fry, the 1998 VA examination, and his hearing testimony, the veteran (a) has to get up to urinate 1-2 times per night (nocturia), (b) complains of urinary frequency which Dr. Fry classified as "mild" (but his bladder empties adequately and stream is also adequate), and (c) has slight "stress" incontinence or leakage in certain positions (but does not need to wear absorbent pads, although he changes his clothing twice per day). The veteran's complaints are consistent with those contemplated for a 10 percent rating (awakening to void two times per night). He is not "required" to wear absorbent materials, as needed for a 20 percent rating. Because there is no evidence that the veteran's daytime voiding interval is between 1-2 hours, or that he awakens to void 3-4 times per night, or that he must wear absorbent materials, an evaluation higher than 10 percent is not warranted. Although the Board recognizes that having cancer was a frightening experience for the veteran, as he stated in his substantive appeal, the rating Schedule does not provide for a disability rating higher than 10 percent, following cessation of treatment for prostate cancer, unless the criteria discussed above are met. The Board has considered whether any other diagnostic codes are potentially applicable to the veteran's condition. However, Diagnostic Code 7528 is the only diagnostic code pertinent to residuals of any genitourinary cancer, and evaluations have been considered under all the criteria applicable to voiding dysfunction, since the veteran does not have renal dysfunction. The Board notes that from the testimony presented in 1999, a major residual of the veteran's prostate cancer is his psychiatric symptomatology (i.e., personality changes, increased anger, etc.), and he is receiving a separate 10 percent disability rating for these symptoms. 2. Impotence The veteran has been granted service connection for impotence, which has resulted from the prostatectomy for his prostate cancer. He is currently assigned a zero percent disability rating for this condition under 38 C.F.R. § 4.115b, Diagnostic Code 7522. Sexual impotence itself does not have a specific diagnostic code. When a veteran is diagnosed with an unlisted condition, it must be rated under a closely related disease or injury where the affected functions, anatomical location, and symptomatology are closely analogous. 38 C.F.R. § 4.20. Therefore, the veteran's sexual impotence is rated as analogous to a penile deformity with loss of erectile power under Diagnostic Code 7522. A compensable evaluation under Diagnostic Code 7522 requires both deformity of the penis and loss of erectile power. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The medical evidence does not show that the veteran has a penile deformity. Not only is it necessary that a claimant has loss of erectile power under Diagnostic Code 7522, but there must be penile deformity as well. Therefore, since the required residuals for a compensable evaluation are not shown, a compensable evaluation for the veteran's sexual impotence is not warranted. 38 C.F.R. §§ 4.7, 4.20, and 4.115b, Diagnostic Code 7522. There is no reasonable doubt regarding the level of the veteran's disability. Although the Board is sympathetic to the difficulties caused by the veteran's impotence, and its effect on his life and relationship with his spouse, a compensable rating cannot be assigned without evidence of penile deformity. The Board again notes that the veteran is receiving special monthly compensation benefits by reason of sexual impotence under 38 C.F.R. § 3.350(a) on account of loss of use of a creative organ. The Board has considered whether any other diagnostic codes are potentially applicable to the veteran's condition. However, Diagnostic Code 7522 is the only analogous diagnostic code for sexual impotence. ORDER Having found the claim not well grounded, entitlement to service connection for hearing loss is denied. The claim of entitlement to service connection for asbestosis is well grounded, and, to that extent only, the appeal is granted. Entitlement to an initial disability rating higher than 10 percent for residuals of prostate cancer is denied. Entitlement to an initial compensable disability rating for impotence is denied. REMAND In order to ensure that the Board has a complete record upon which to decide the veteran's claim for service connection for asbestosis, additional evidentiary development is needed. With asbestos-related claims, the Board must determine whether the claim development procedures applicable to such claims have been followed. Ashford v. Brown, 10 Vet. App. 120, 124-125 (1997) (while holding that the veteran's claim had been properly developed and adjudicated, the Court indicated that the Board should have specifically referenced the DVB Circular and discussed the RO's compliance with the Circular's claim-development procedures). With these claims, the RO must determine whether military records demonstrate evidence of asbestos exposure during service, develop whether there was pre-service and/or post-service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease, keeping in mind the latency and exposure information discussed above. M21-1, Part VI, 7.21(d)(1), p. 7-IV-3 and 7-IV-4 (January 31, 1997). The radiographic changes that would be indicative of asbestos exposure include interstitial pulmonary fibrosis (asbestosis), pleural effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum. M21-1, Part VI, 7.21(a)(1), p. 7-IV-3 (January 31, 1997). As discussed above, a 1985 chest x-ray showed interstitial pulmonary fibrosis, which, according to M21-1, would be indicative of asbestos-related disease. The Board does not know if the findings reported by Dr. Fletcher (increased interstitial markings) have the same medical significance as interstitial pulmonary fibrosis. Although the RO attempted to thoroughly develop the evidence for the Board's review, the medical evidence in this case as to whether the veteran in fact has asbestosis is contradictory. For this reason, the veteran underwent a second VA examination in 1999, wherein the examiner, in conjunction with a pulmonologist, reviewed the findings from the chest x-ray and CT scan performed during the 1998 VA examination as compared to Dr. Fletcher's records, and concluded that there was no clinical evidence of asbestosis. However, the negative 1998 findings pre-dated Dr. Fletcher's findings, and do not, therefore, negate Dr. Fletcher's conclusions. The Board cannot decide the veteran's claim based on Dr. Fletcher's records alone, since the medical evidence is so inconsistent (i.e., abnormalities in 1985, none in 1998, additional abnormalities in 1999), and the Board cannot make a decision based on its own unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Therefore, it is necessary that additional diagnostic testing be done that will conclusively demonstrate whether the veteran currently has asbestosis. Also, there is no indication that Dr. Fletcher's opinion was based upon review of pertinent medical evidence. It is necessary that a medical professional review the veteran's claims file, including the service medical records, and provide an opinion as to the likelihood that any current asbestos-related disease is related to the veteran's military service. A medical opinion is needed, since there is not sufficient evidence upon which the Board can decide the claim. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991); Santiago v. Brown, 5 Vet. App. 288, 292 (1993). Furthermore, during the 1998 VA examination, the veteran stated that he was first diagnosed with asbestosis in 1987 or 1988 when chest x-rays were conducted in conjunction with knee surgery. It is not known where these x-rays were conducted, but they would certainly be relevant to the claim for service connection, particularly since the current medical evidence of record is contradictory as to the existence of asbestosis. Therefore, an attempt to obtain these records is warranted. Robinette v. Brown, 8 Vet. App. 69 (1995). Accordingly, while the Board regrets the delay, this claim is REMANDED for the following: 1. The RO should ask the veteran to complete the appropriate documentation authorizing the VA to obtain his medical records from whichever medical facility and/or physician conducted chest x-rays in 1987 or 1988 that allegedly showed evidence of asbestosis. If the request is unsuccessful, the RO should advise the veteran that these records are important to his claim and that it is his responsibility to submit them. See 38 C.F.R. § 3.159(c). The RO should provide the veteran with an appropriate period of time within which to respond and/or submit the records. 2. After the above evidence has been obtained, the RO should schedule the veteran for a VA examination with a pulmonary specialist. The specialist must be provided with the entire claims folder and a copy of this remand prior to the examination. The specialist must indicate in the report that the entire claims file was reviewed, and he or she must provide a complete and detailed rationale for all conclusions and opinions. The specialist should perform all necessary tests in order to determine whether the veteran currently has asbestosis or any other asbestos-related disease. Prior to rendering the following opinions, the examiner should review all the evidence of record, including, but not limited to, the service medical records; the 1985 chest x-ray report showing interstitial pulmonary fibrosis; the veteran's statements concerning the circumstances surrounding the in-service exposure to asbestos (see, e.g., November 1998 handwritten statement and 1999 hearing testimony) versus post-service exposure to asbestos (see 1998 VA examination report); the 1998 and 1999 VA examination reports; and the records/opinion from Dr. Fletcher. Following the examination of the veteran, the specialist should render an opinion as to whether the veteran currently has asbestos-related disease, and, if so, whether it is at least as likely as not that the current disorder is related to in-service asbestos exposure. In rendering these opinions, the specialist must reconcile the contradictory medical evidence of record as to the current existence of asbestosis. The specialist should also discuss evidence in the record that could indicate other possible etiologies for development of a lung disorder, such as the veteran's exposure in 1967 to a fellow servicemember who had tuberculosis, and the veteran's history of cigarette smoking. 3. Subsequently, the RO should review the claims folder and ensure that all of the above development actions have been conducted and completed in full and that the requested opinions are in compliance with the directives of this REMAND. If the report is deficient in any manner or fails to include adequate responses to the specific questions requested, it must be returned to the specialist for correction. 38 C.F.R. § 4.2; see also Stegall v. West, 11 Vet. App. 268 (1998). 4. Thereafter, the RO should readjudicate the veteran's claim for service connection for asbestosis, with consideration of the entire record and all applicable laws and regulations. In adjudicating the claim, the RO should take into consideration with heighten mindfulness the benefit of the doubt rule. 38 U.S.C.A. § 5107(b). If the evidence is not in equipoise, the RO should explain why. See Cartwright v. Derwinski, 2 Vet. App. 24, 26 (1991). 5. The veteran is hereby informed that he has the right to submit additional evidence and argument on the matter that the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). He is further advised that he should assist the RO in the development of his claim, and that failure to cooperate or to report for any requested examination without good cause may result in an adverse decision. See 38 C.F.R. §§ 3.158 and 3.655; Wood v. Derwinski, 1 Vet. App. 191, 193 (1991). If the benefit sought on appeal remains denied, the RO should provide the veteran a supplemental statement of the case, and he should be afforded a reasonable period of time within which to respond thereto. Then, the entire claims folder should be returned to the Board for further appellate consideration, if in order. The veteran need take no action until he is so informed. The purpose of this REMAND is to obtain additional evidence. No inference should be drawn regarding the final disposition of this claim as a result of this action. This claim must be afforded expeditious treatment by the RO. 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 The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (Historical and Statutory Notes) (West Supp. 2000). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. JOAQUIN AGUAYO-PERELES Member, Board of Veterans' Appeals