Citation Nr: 0810939 Decision Date: 04/03/08 Archive Date: 04/14/08 DOCKET NO. 06-05 759 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a rating in excess of 20 percent for diabetes mellitus with impotence and nephropathy. 2. Entitlement to a rating in excess of 10 percent for chondromalacia, left knee. 3. Entitlement to a rating in excess of 10 percent for chondromalacia, right knee. 4. Entitlement to a compensable rating for left ear hearing loss. 5. Entitlement to service connection for post traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Katz, Associate Counsel INTRODUCTION The veteran served on active duty from May 1971 to May 1974 and from May 1975 to May 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Board also notes that additional evidence has been received since the case was certified for appeal. That evidence includes an October 2007 written statement from the veteran requesting a review of all the evidence of record. This evidence was received after the last RO review. The Board has, accordingly, reviewed the additional evidence and is of the opinion that RO review is not required. While it discussed the various issues on appeal, the veteran makes the same contentions that he has all along, and reference to certain evidence already of record. Accordingly, the Board concludes that there is no prejudice in proceeding with consideration of this case without affording the RO an opportunity to review the evidence in question. The issue of entitlement to service connection for PTSD is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the entire period on appeal, the veteran's diabetes mellitus with impotence and nephropathy has been manifested by the need for daily oral hypoglycemic agents, insulin, and dietary restrictions, but his physical activity has not been clinically regulated. 2. For the entire period on appeal, the veteran's chondromalacia of the left knee has not resulted in limitation of flexion to 30 degrees or less nor limitation of extension to 15 degrees or more. 3. For the entire period on appeal, the veteran's chondromalacia of the right knee has not resulted in limitation of flexion to 30 degrees or less nor limitation of extension to 15 degrees or more. 4. For the entire appeal period, the veteran's left ear hearing loss has been documented to be no worse than Level IV. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for diabetes mellitus with impotence and nephropathy have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.2, 4.3, 4.6, 4.7, 4.84, 4.119, Diagnostic Code (DC) 7913 (2007). 2. The criteria for a rating in excess of 10 percent for chondromalacia, left knee, have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, DCs 5260, 5261 (2007). 3. The criteria for a rating in excess of 10 percent for chondromalacia, right knee, have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, DCs 5260, 5261 (2007). 4. The criteria for a compensable rating for left ear hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85- 4.87, DC 6100 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining the level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Diabetes Mellitus The veteran is currently rated as 20 percent disabled for diabetes under DC 7913. For an increased rating (40 percent), the veteran must show diabetes requiring insulin, restricted diet, and regulation of activities. Id. The threshold requirement is the regulation of activities. In this case, the evidence does not demonstrate that he has been prescribed or advised to avoid strenuous occupational and recreational activities. See 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining "regulation of activities," as used by VA in DC 7913). The veteran contends that his activities have been restricted as a result of his diabetes mellitus. The records show ongoing treatment for diabetes which is largely uncontrolled. The July 2003 VA examination report indicates that he required insulin and is on a low fat diet. Therefore, two of the three criteria for a higher rating have been satisfied. Although he reported at the VA examination that "he gets tired very easily if he exerts himself especially in hot weather." He further indicated that he could no longer engage in sports activities as he did in the past and sometimes had difficulty doing simple chores around the house, such as yard work. He also reported having been hospitalized for a hypoglycemic reaction in 2001 but not since then, and having two to three episodes of hypoglycemia per week characterized by shakiness. Nonetheless, the evidence does not indicate that he veteran has been prescribed or advised to avoid strenuous occupational and recreational activities due to his type II diabetes mellitus, as is required to merit a higher rating of 40 percent. Moreover, the limitation in his activity as described in the VA examination was attributed to his service-connected knee disabilities, not to diabetes. While the veteran here has been prescribed a restricted diet and insulin in effort to control his diabetes, he has not been prescribed limited physical activity or advised to avoid recreational activities. He, therefore, does not meet the criteria for a higher rating. 38 C.F.R. § 4.119, DC 7913; see also Camacho v. Nicholson, 21 Vet. App. 360 (2007) (medical evidence is required to show occupational and recreational activities have been restricted). Here, the veteran reported having been hospitalized for a hypoglycemic reaction prior to the period on appeal in 2001 but not since then. The veteran reported having two to three episodes of hypoglycemia per week characterized by shakiness. Without further complications or treatment for hypoglycemic reactions, the symptoms of diabetes mellitus do not more nearly approximate a rating in excess of 40 percent. Chondromalacia - Knees The veteran is currently rated as 10 percent disabled under 38 C.F.R. § 4.71a for both his right and left knees. For an increased rating, the veteran must show either: ? limitation of flexion to 30 degrees (20 percent under DC 5260), or ? limitation of extension to 15 degrees (20 percent under DC 5261). Also to be considered in evaluating musculoskeletal 1. Entitlement to a rating in excess of 20 percent for diabetes mellitus with impotence and nephropathy. 2. Entitlement to a rating in excess of 10 percent for chondromalacia, left knee. 3. Entitlement to a rating in excess of 10 percent for chondromalacia, right knee. 4. Entitlement to a compensable rating for left ear hearing loss. 5. Entitlement to service connection for post traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Katz, Associate Counsel INTRODUCTION The veteran served on active duty from May 1971 to May 1974 and from May 1975 to May 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Board also notes that additional evidence has been received since the case was certified for appeal. That evidence includes an October 2007 written statement from the veteran requesting a review of all the evidence of record. This evidence was received after the last RO review. The Board has, accordingly, reviewed the additional evidence and is of the opinion that RO review is not required. While it discussed the various issues on appeal, the veteran makes the same contentions that he has all along, and reference to certain evidence already of record. Accordingly, the Board concludes that there is no prejudice in proceeding with consideration of this case without affording the RO an opportunity to review the evidence in question. The issue of entitlement to service connection for PTSD is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the entire period on appeal, the veteran's diabetes mellitus with impotence and nephropathy has been manifested by the need for daily oral hypoglycemic agents, insulin, and dietary restrictions, but his physical activity has not been clinically regulated. 2. For the entire period on appeal, the veteran's chondromalacia of the left knee has not resulted in limitation of flexion to 30 degrees or less nor limitation of extension to 15 degrees or more. 3. For the entire period on appeal, the veteran's chondromalacia of the right knee has not resulted in limitation of flexion to 30 degrees or less nor limitation of extension to 15 degrees or more. 4. For the entire appeal period, the veteran's left ear hearing loss has been documented to be no worse than Level IV. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for diabetes mellitus with impotence and nephropathy have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.2, 4.3, 4.6, 4.7, 4.84, 4.119, Diagnostic Code (DC) 7913 (2007). 2. The criteria for a rating in excess of 10 percent for chondromalacia, left knee, have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, DCs 5260, 5261 (2007). 3. The criteria for a rating in excess of 10 percent for chondromalacia, right knee, have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, DCs 5260, 5261 (2007). 4. The criteria for a compensable rating for left ear hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85- 4.87, DC 6100 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining the level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Diabetes Mellitus The veteran is currently rated as 20 percent disabled for diabetes under DC 7913. For an increased rating (40 percent), the veteran must show diabetes requiring insulin, restricted diet, and regulation of activities. Id. The threshold requirement is the regulation of activities. In this case, the evidence does not demonstrate that he has been prescribed or advised to avoid strenuous occupational and recreational activities. See 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining "regulation of activities," as used by VA in DC 7913). The veteran contends that his activities have been restricted as a result of his diabetes mellitus. The records show ongoing treatment for diabetes which is largely uncontrolled. The July 2003 VA examination report indicates that he required insulin and is on a low fat diet. Therefore, two of the three criteria for a higher rating have been satisfied. Although he reported at the VA examination that "he gets tired very easily if he exerts himself especially in hot weather." He further indicated that he could no longer engage in sports activities as he did in the past and sometimes had difficulty doing simple chores around the house, such as yard work. He also reported having been hospitalized for a hypoglycemic reaction in 2001 but not since then, and having two to three episodes of hypoglycemia per week characterized by shakiness. Nonetheless, the evidence does not indicate that he veteran has been prescribed or advised to avoid strenuous occupational and recreational activities due to his type II diabetes mellitus, as is required to merit a higher rating of 40 percent. Moreover, the limitation in his activity as described in the VA examination was attributed to his service-connected knee disabilities, not to diabetes. While the veteran here has been prescribed a restricted diet and insulin in effort to control his diabetes, he has not been prescribed limited physical activity or advised to avoid recreational activities. He, therefore, does not meet the criteria for a higher rating. 38 C.F.R. § 4.119, DC 7913; see also Camacho v. Nicholson, 21 Vet. App. 360 (2007) (medical evidence is required to show occupational and recreational activities have been restricted). Here, the veteran reported having been hospitalized for a hypoglycemic reaction prior to the period on appeal in 2001 but not since then. The veteran reported having two to three episodes of hypoglycemia per week characterized by shakiness. Without further complications or treatment for hypoglycemic reactions, the symptoms of diabetes mellitus do not more nearly approximate a rating in excess of 40 percent. Chondromalacia - Knees The veteran is currently rated as 10 percent disabled under 38 C.F.R. § 4.71a for both his right and left knees. For an increased rating, the veteran must show either: ? limitation of flexion to 30 degrees (20 percent under DC 5260), or ? limitation of extension to 15 degrees (20 percent under DC 5261). Also to be considered in evaluating musculoskeletal disabilities based on limitation of motion, the Board must assess functional impairment and determine the extent to which a service connected disability adversely affects the ability of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Ratings based on limitation of motion do not subsume the various rating factors in 38 C.F.R. §§ 4.40 and 4.45, which include pain, more motion than normal, less motion than normal, incoordination, weakness, and fatigability. These regulations, and the prohibition against pyramiding in 38 C.F.R. § 4.14, do not forbid consideration of a higher rating based on a greater limitation of motion due to pain on use, including flare-ups. DeLuca v. Brown, 8 Vet. App. 202, 206- 08 (1995). In other words, when rated for limitation of motion, a higher rating may be assigned if there is additional limitation of motion from pain or limited motion on repeated use of the joint. A finding of functional loss due to pain must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." 38 C.F.R. § 4.40. In a July 2003 VA examination, the veteran's flexion was noted to be to 90 degrees for the left knee and 80 degrees for the right knee, both with pain which worsened at 70 degrees. Extension was full to 0 degrees but also with pain. The examination report indicates that he refused to have repetitive motion tested because he reported that he was having a flare-up. He reported that he was able to do all activities unless he was having a flare-up. Based on the range of motion measured on examination, the veteran's knee disability does not more nearly approximate a higher rating. The range of motion of neither knee indicated limitation of flexion or extension to an extent such as to warrant an increased rating and while he claimed to have decreased range of motion due to painful flare-ups, he refused repetitive motion testing that could have more accurately displayed this claim. While the veteran reported having a flare-up at the examination, no other flare-ups were reported in the treatment records and he reported that he was able to do all activities when not having a flare-up. The evidence of record does not indicate knee disabilities that would more nearly approximate a higher rating and his claims for increased ratings for his knees must therefore be denied. Left Ear Hearing Loss The veteran's left ear hearing loss is currently rated as noncompensable. His hearing was tested during the period on appeal at a July 2003 VA examination. Pure tone thresholds, decibels, were as follows: HERTZ 500 1000 2000 3000 4000 LEFT 35 30 50 60 80 Speech audiometry revealed speech recognition ability of 80 percent in the left ear. The diagnosis was mild sensorineural hearing loss from 500 through 1500 Hz, sloping to moderate at 2000 Hz, moderately severe at 3000 Hz, and severe at 4000 Hz. VA rating criteria for the evaluation of hearing loss provide ratings from zero (noncompensable) to 100 percent, based on the results of controlled speech discrimination tests together with the results of pure tone audiometry tests which average pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz. 38 C.F.R. §§ 4.85 through 4.87; DCs 6100 through 6110. The evaluation of hearing impairment applies a structured formula which is essentially a mechanical application of the rating schedule to numeric designations after audiology evaluations are done. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Under Table VI, the veteran's left ear hearing loss is considered to be Level IV. The veteran's right ear is considered to be Level I for rating purposes because it is not service-connected for hearing loss. 38 C.F.R. § 4.85(f). Using the above hearing levels and Table VII, his left ear hearing loss is determined to render a noncompensable disability rating. As a result, his claim for an increased disability rating must fail. With regards to all the claims for increased ratings, the Board has considered the veteran's statements and sworn testimony regarding his service-connected disabilities on appeal. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the later is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. Layno, 6 Vet. App. at 470. As a lay person, however, he is not competent to offer opinions on medical diagnosis, and the Board may not accept unsupported lay speculation with regard to medical issues. See Moray v. Brown, 5 Vet. App. 211 (1993); Espiritu v. Derwinski, 2 Vet. App. 482 (1992). As noted, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. The Board finds that the medical findings, which directly address the criteria under which the service- connected disability is evaluated, more probative than the subjective evidence of an increased disability. Finally, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a 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 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice errors are presumed prejudicial unless VA shows that the error did not affect the essential fairness of the adjudication. To overcome the burden of prejudicial error, VA must show (1) that any defect was cured by actual knowledge on the part of the claimant; (2) that a reasonable person could be expected to understand from the notice what was needed; or, (3) that a benefit could not have been awarded as a matter of law. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). The veteran's claim for increased rating for diabetes mellitus arises from his disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. As to VA's duty to assist, VA has associated with the claims folder the veteran's private and VA treatment records, and in July 2003, he was afforded a formal VA examination. The Board finds that no additional assistance is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). For the increased-compensation claims relating to the veteran's knees and hearing loss, § 5103(a) requires, at a minimum, that VA notify the claimant that, to substantiate a claim, the medical or lay evidence must show a worsening or increase in severity of the disability, and the effect that such worsening or increase has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Further, if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on employment and daily life (such as a specific measurement or test result), VA must provide at least general notice of that requirement. VA must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation. Id. In this case, a letter satisfying the notice requirements under 38 C.F.R. § 3.159(b)(1) was sent to the veteran in July 2003, prior to the initial RO decision that is the subject of this appeal. The letter informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. He was also asked to submit evidence and/or information in his possession to the RO. Moreover, with respect to the Dingess requirements, the veteran was given notice of what type of information and evidence he needed to substantiate his claims for an increased rating as this is the premise of the claims. It is therefore inherent that the he had actual knowledge of the rating element of the claims. The Board acknowledges that the VCAA letter sent to the veteran in July 2003 does not meet the requirements of Vazquez-Flores and is not sufficient as to content and timing, creating a presumption of prejudice. Nonetheless, such presumption has been overcome for the reasons discussed below. In this case, the veteran was provided with correspondence regarding what was needed to support his claims. Specifically, the rating decision dated September 2003 explained what was necessary for increased ratings regarding these claims and the December 2005 statement of the case reiterated the information and included the actual diagnostic codes that are relevant to his claims. Based on the evidence above, the veteran can be expected to understand from the various correspondence from the RO what was needed to support his claims. Moreover, the veteran demonstrated actual knowledge of what was needed to support his claims as reflected in his statements and correspondence. Specifically, he indicated a knowledge of what was generally required for an increased rating in his notice of disagreement and written statements which also reflected an understanding of the rating schedule itself. Based on the above, the notice deficiencies do not affect the essential fairness of the adjudication. Therefore, the presumption of prejudice is rebutted. For this reason, no further development is required regarding the duty to notify. Next, VA has a duty to assist the veteran in the development of the claim. This duty includes assisting him in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Specifically, the RO obtained VA treatment records and he submitted private treatment records. In addition, he was afforded VA medical examinations in July 2003 regarding each of his claims. Significantly, neither the veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER A rating in excess of 20 percent for diabetes mellitus with impotence and nephropathy is denied. A rating in excess of 10 percent for chondromalacia of the left knee is denied. A rating in excess of 10 percent for chondromalacia of the right knee is denied. A compensable rating for left ear hearing loss is denied. REMAND The veteran claims that he has PTSD as a result of stressors incurred in service in Vietnam. His service personnel records indicate that he served with the 180th Aviation Company in Vietnam in 1972. Specifically, it appears that he served as a gunner in the 180th Assault Support Helicopter Company 7/17th Cav USARPAC-RVN from January 19, 1972, to April 28, 1972. The veteran asserts that while serving in this position, he helped retrieve the bodies of fallen and wounded soldiers. Further development of his claimed in-service stressors must be conducted prior to a decision on this issue. Accordingly, the case is REMANDED for the following actions: 1. The RO should attempt to verify the veteran's stressor with the U.S. Army and Joint Services Records Research Center (JSRRC) or other appropriate organization. Specifically, obtain the unit records for the 180th Aviation Company/180th Assault Support Helicopter Company from January 19, 1972, to March 1, 1972, and, in a separate request, from March 1, 1972 to April 28, 1972, regarding whether the unit served missions to retrieve dead or wounded soldiers, or if they lost any helicopters or soldiers. 2. Thereafter, readjudicate the claim on appeal and if it remains denied issue the veteran and his representative a supplemental statement of the case and allow an appropriate period for response. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. All claims remanded by the Board 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. 2007). ______________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs