Citation Nr: 0813170 Decision Date: 04/22/08 Archive Date: 05/01/08 DOCKET NO. 04-17 767 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for fracture of ribs, left side. 3. Entitlement to service connection for a left ankle sprain. 4. Entitlement to service connection for Guillain-Barré syndrome. 5. Entitlement to service connection for fracture of right thumb. 6. Entitlement to service connection for fracture of second and third toes, left foot. 7. Entitlement to service connection for right elbow strain. 8. Entitlement to service connection for left shoulder strain. 9. Entitlement to service connection for left wrist strain. 10. Entitlement to service connection for left knee strain. 11. Entitlement to service connection for fracture of right hand. 12. Entitlement to service connection for left hip strain. 13. Entitlement to service connection for sciatica to left hip. 14. Entitlement to service connection for fracture of right fifth finger. 15. Entitlement to service connection for a peptic ulcer. 16. Entitlement to service connection for hypertension. 17. Entitlement to service connection for chronic upper respiratory infection. 18. Entitlement to service connection for renal failure. 19. Entitlement to service connection for hyperlipidemia. 20. Entitlement to service connection for gastroenteritis. 21. Entitlement to an initial evaluation in excess of 40 percent for diabetes mellitus with early diabetic nephropathy and impotence. 22. Entitlement to an initial evaluation in excess of 10 percent for status post laparotomy and cholecystectomy, history of Gilbert's syndrome. 23. Entitlement to an initial evaluation in excess of 10 percent for tinnitus. 24. Entitlement to an initial evaluation in excess of 10 percent for acoustic neuroma of cochlear nerve, left ear, status post translabyrinth resection. 25. Entitlement to an initial compensable evaluation for hemorrhoids. 26. Entitlement to an initial evaluation in excess of 10 percent for fracture of first phalanx of fifth toe, left foot. 27. Entitlement to an initial evaluation in excess of 10 percent for hallux rigidus, right great toe. 28. Entitlement to an initial compensable evaluation for scar, laceration of left thumb. 29. Entitlement to an initial evaluation in excess of 10 percent for lumbar strain with mild diffuse lumbar spondylosis. 30. Entitlement to an initial evaluation in excess of 10 percent for cervical strain with mild diffuse cervical spondylosis. 31. Entitlement to an initial evaluation in excess of 10 percent for gastroesophageal reflux disease (GERD). 32. Entitlement to an initial evaluation in excess of 10 percent for coronary artery disease. 33. Entitlement to an initial evaluation in excess of 10 percent for tinea cruris of groin, eczema of arms and keratosis pilaris of left foot. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. J. N. Driever, Counsel INTRODUCTION The veteran had active service from February 1977 to December 1979 and from March 1982 to August 2002. These claims come before the Board of Veterans' Appeals (Board) on appeal of a February 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In a VA Form 9 (Appeal to Board of Veterans' Appeals) received in April 2004, the veteran requested a Board hearing at the RO. The RO scheduled the veteran for such a hearing in November 2007, but on that date, the veteran failed to appear. Inasmuch as the veteran did not request postponement of the hearing, the Board considers the hearing request withdrawn. The Board addresses the claims of entitlement to service connection for a left ankle sprain, Guillain-Barré syndrome, fracture of right thumb, fracture of second and third toes, left foot, right elbow strain, left shoulder strain, left wrist strain, left knee strain, and fracture of right hand, and entitlement to higher initial evaluations for diabetes mellitus with early diabetic nephropathy and impotence, status post laparotomy and cholecystectomy, history of Gilbert's syndrome, acoustic neuroma of cochlear nerve, left ear, status post translabyrinth resection, hemorrhoids, fracture of first phalanx of fifth toe, left foot, hallux rigidus, right great toe, scar, laceration of left thumb, lumbar strain with mild diffuse lumbar spondylosis, cervical strain with mild diffuse cervical spondylosis, GERD, coronary artery disease, tinea cruris of groin, eczema of arms and keratosis pilaris of left foot in the Remand section of this decision, below, and REMANDS these claims to the RO via the Appeals Management Center (AMC) in Washington, D.C. FINDINGS OF FACT 1. VA provided the veteran adequate notice and assistance with regard to the claims being decided. 2. The veteran does not currently have right ear hearing loss by VA standards. 3. The veteran does not currently have residuals of fractured ribs, left side. 4. The veteran does not currently have a left hip strain or sciatica. 5. The veteran does not currently have residuals of a fracture of the right fifth finger. 6. The veteran does not currently have a peptic ulcer. 7. The veteran does not currently have hypertension. 8. The veteran does not currently have a chronic upper respiratory infection. 9. The veteran does not currently have renal failure. 10. The veteran does not currently have a disability manifested by hyperlipidemia. 11. The veteran does not currently have gastroenteritis. 12. The veteran is currently in receipt of a 10 percent evaluation for tinnitus, the maximum schedular evaluation available for tinnitus, whether perceived in one ear or both ears. 13. The veteran's tinnitus does not present such an exceptional or unusual disability picture as to render impractical the application of regular schedular standards. CONCLUSIONS OF LAW 1. Right ear hearing loss was not incurred in or aggravated by service and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.385 (2007). 2. Residuals of fractured ribs, left side, were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 3. A left hip strain was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 4. Sciatica to the left hip was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 5. A fracture of the right fifth finger was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 6. A peptic ulcer was not incurred in or aggravated by service and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2007). 7. Hypertension was not incurred in or aggravated by service and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2007). 8. A chronic upper respiratory infection was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 9. Renal failure was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 10. Hyperlipidemia was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 11. Gastroenteritis was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 12. There is no legal basis for entitlement to an initial evaluation in excess of 10 percent for tinnitus. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.87, Diagnostic Code 6260 (2002, 2007); Smith v. Nicholson, 19 Vet. App. 63 (2005) rev'd, 451 F.3d 1344 (Fed. Cir. 2006). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist On November 9, 2000, the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002), became law. Regulations implementing the VCAA were then published at 66 Fed. Reg. 45,620, 45,630-32 (August 29, 2001) and codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2007). The VCAA and its implementing regulations are applicable to this appeal. The VCAA and its implementing regulations provide, in part, that VA will notify the claimant and his representative, if any, of the information and medical or lay evidence not previously provided to the Secretary that is necessary to substantiate a claim. As part of the notice, VA is to specifically inform the claimant and his representative, if any, of which portion of the evidence the claimant is to provide and which portion of the evidence VA will attempt to obtain on the claimant's behalf. They also require VA to assist a claimant in obtaining evidence necessary to substantiate a claim, but such assistance is not required if there is no reasonable possibility that such assistance would aid in substantiating the claim. The United States Court of Appeals for Veterans Claims (Court) has mandated that VA ensure strict compliance with the provisions of the VCAA. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). In this case, as explained below, VA provided the veteran adequate notice and assistance with regard to his claims for service connection such that the Board's decision to proceed in adjudicating those claims does not prejudice the veteran in the disposition thereof. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). VA did not provide the veteran adequate notice and assistance with regard to his claim for an initial evaluation in excess of 10 percent for tinnitus. However, the Court has held that the statutory and regulatory provisions pertaining to VA's duties to notify and assist do not apply to a claim if resolution of that claim is based on statutory interpretation, rather than on consideration of the factual evidence. Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001). Such is the case with regard to this particular claim. Moreover, because the law precludes the veteran's entitlement to a higher initial evaluation for tinnitus, there is no reasonable possibility that further notice or assistance would aid in substantiating the claim. Wensch v. Principi, 15 Vet. App. 362, 368 (2001) (compliance with the VCAA is not required if no reasonable possibility exists that any notice or assistance would aid the appellant in substantiating the claim). A. Duty to Notify The Court has indicated that notice under the VCAA must be given prior to an initial unfavorable decision by the agency of original jurisdiction. In Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 119-20 (2004), the Court also indicated that the VCAA requires VA to provide notice, consistent with the requirements of 38 U.S.C.A. § 5103(A), 38 C.F.R. § 3.159(b), and Quartuccio, that informs 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. In what can be considered a fourth element of the requisite notice, the Court further held that, under 38 C.F.R. § 3.159(b), VA must request the claimant to provide any evidence in his possession that pertains to the claim. Id. at 120-21. In March 2006, the Court held that the aforementioned notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of disability; (3) a connection between service and disability; (4) degree of disability; and (5) effective date of disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006). The Court further held that notice under the VCAA must inform the claimant that, if the RO grants his service connection claim, it will then assign such an award a disability rating and an effective date. Id. at 486. In this case, the RO provided the veteran VCAA notice on his claims for service connection by letter dated August 2004, before initially deciding those claims in a rating decision dated December 2004. The timing of such notice reflects compliance with the requirements of the law as found by the Court in Pelegrini II. The content of such notice also reflects compliance with the requirements of the law as found by the Court in Pelegrini II. In the letter, the RO acknowledged the veteran's claims for service connection, notified the veteran of the evidence needed to substantiate those claims, identified the type of evidence that would best do so, informed him of VA's duty to assist, and indicated that it was developing his claims pursuant to that duty. The RO also identified the evidence it had received in support of the veteran's claims and the evidence it was responsible for securing. The RO noted that it would make reasonable efforts to assist the veteran in obtaining all outstanding evidence provided she identified the source(s) thereof. The RO also noted that, ultimately, it was the veteran's responsibility to ensure VA's receipt of all pertinent evidence. The RO advised the veteran to sign the enclosed forms authorizing the release of his treatment records if he wished VA to obtain such records on his behalf. The RO also advised the veteran to identify or send directly to VA any evidence he had in his possession that pertained to his claims. The content of the notice letter does not reflect compliance with the requirements of the law as found by the Court in Dingess/Hartman. Therein, the RO did not provide the veteran information on disability ratings or effective dates. The veteran has not, however, been prejudiced as a result thereof. Bernard, 4 Vet. App. at 394. Rather, as explained below, service connection may not be granted in this case; therefore, any question regarding what disability rating or effective date to assign a grant of service connection is moot. B. Duty to Assist VA made reasonable efforts to identify and obtain relevant records in support of the veteran's claims for service connection. 38 U.S.C.A. § 5103A(a), (b), (c) (West 2002). Specifically, the RO secured and associated with the claims file all evidence the veteran identified as being pertinent to his claims, including service medical records and post- service treatment records. Since then, the veteran has not indicated that there is other information or evidence to secure in support of his claims. The RO also conducted medical inquiry in support of the claims by affording the veteran VA examinations, during which VA examiners addressed the etiology and severity of the disabilities at issue in this decision. The veteran does not now assert that the reports of these examinations are inadequate to decide the claims at issue. Under the facts of this case, "the record has been fully developed," and "it is difficult to discern what additional guidance VA could have provided to the veteran regarding what additional evidence he should submit to substantiate his claim[s]." Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004); see also Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the claimant). II. Analysis of Claims A. Claims for Service Connection The veteran claims entitlement to service connection for right ear hearing loss, residuals of fractured ribs, left hip and right fifth finger disabilities, a peptic ulcer, hypertension, an upper respiratory infection, renal failure, hyperlipidemia and gastroenteritis. His representative specifically asserts that the veteran initially manifested some of these disabilities during active service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2007). In cases involving service connection for hearing loss, impaired hearing will be considered to be a disease when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 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. 38 C.F.R. § 3.385 (2007). Subsequent manifestations of a chronic disease in service, however remote, are to be service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or diagnosis including the word "chronic." Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2007). Service connection may be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2007). Service connection may be presumed for arthritis, and an organic disease of the nervous system, which includes sensorineural hearing loss, cardiovascular-renal disease, including hypertension, and peptic ulcers if the veteran served continuously for 90 days or more during a period of war or during peacetime after December 31, 1946, and one of these conditions became manifest to a degree of 10 percent within one year from the date of discharge, and there is no evidence of record establishing otherwise. 38 U.S.C.A. §§ 1101(3), 1112(a), 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307(a)(1)-(3), 3.309(a) (2007). In order to prevail with regard to the issue of service connection on the merits, there must be medical evidence of a current disability, see Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The veteran's service medical records establish that, prior to and during service, the veteran received treatment for complaints associated with his digestive and gastrointestinal systems. During service, the veteran also received treatment for upper respiratory infections and right fifth finger complaints. Medical professionals diagnosed, in part, hyperlipidemia, peptic ulcer disease and gastroenteritits. They did not diagnose hypertension or renal failure and noted normal right ear hearing. In-service x-rays revealed no abnormalities of the ribs, left hip or right fifth finger. Since discharge, the veteran has not identified any records of post-service medical treatment, which would establish that he is receiving treatment for the conditions at issue in this decision. He has, however, undergone VA examinations of the alleged conditions. During these examinations, conducted in December 2002 and January 2003, the veteran reported that he had no complications of, or functional impairment secondary to, fractured ribs or the renal failure he once experienced when taking Baycol. He also reported that he had hyperlipidemia secondary to his diabetes, which is service- connected. Examiners noted normal blood pressure and right ear hearing and no abnormalities of the ribs, left hip and right fifth finger. X-rays of the chest, left rib, left hip and right hand were negative. An upper gastrointestinal series revealed gastroesophageal reflux, but no other abnormalities, including ulcerations. VA examiners diagnosed normal auditory acuity in the right ear, a fractured rib on the left side, subjective without residuals, a left hip strain, no residuals of a fractured right fifth finger, no pathology to render diagnoses of an upper respiratory infection, hypertension, peptic ulcer and renal failure, and resolved gastroenteritis. They did not note hyperlipidemia or any disability manifested thereby. They attributed the veteran's digestive and gastrointestinal system abnormalities to gastroesophageal reflux disease, which is service connected. As noted above, to prevail in a claim for service connection, the veteran must submit competent evidence establishing that he has a current disability resulting from service. In this case, the veteran's assertions represent the only evidence of record establishing that he currently has the conditions at issue in this decision. (Although a VA examiner diagnosed a left hip strain, he noted no left hip abnormalities to support such a diagnosis; in fact, in the body of his VA examination report, he referred to the left hip as normal.) Such assertions may not be considered competent evidence of current disabilities as the record does not reflect that the veteran possesses a recognized degree of medical knowledge to diagnose a medical condition. Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992) (holding that laypersons are not competent to offer medical opinions). Inasmuch as there is no competent medical evidence of record diagnosing right ear hearing loss by VA standards, residuals of fractured ribs, left hip and right fifth finger disabilities, a peptic ulcer, hypertension, an upper respiratory infection, renal failure, hyperlipidemia and gastroenteritis, the Board concludes that such disabilities were not incurred in or aggravated by service. The Board further concludes that the right ear hearing loss, peptic ulcer and hypertension may not be presumed to have been so incurred. The evidence in each of these cases is not in relative equipoise; therefore, the veteran may not be afforded the benefit of the doubt in the resolution of his claims. Rather, as a preponderance of the evidence is against each claim, such claims must be denied. B. Claim for a Higher Initial Evaluation The veteran seeks an evaluation in excess of 10 percent for the tinnitus on the basis that it has worsened. He asserts that the evaluation initially assigned this disability does not accurately reflect the severity of associated symptomatology. His representative requests that VA afford the veteran another VA examination of his ears because the last examination was conducted approximately five years ago. Disability evaluations are determined by evaluating the extent to which a service-connected disability adversely affects a veteran's ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2007). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7 (2007). Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). In claims for increases, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). A disability may require re-evaluation in accordance with changes in a veteran's condition. In determining the level of current impairment, it is thus essential that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. The veteran filed a claim for service connection for tinnitus in September 2002. In a rating decision dated February 2003, the RO granted the veteran service connection for tinnitus and assigned that disability a 10 percent evaluation pursuant to Diagnostic Code (DC) 6260. Thereafter, effective June 13, 2003, this DC was revised, in part, to clarify then existing VA practice allowing for a single 10 percent evaluation whether tinnitus was perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, DC 6260, Note (2) (2007). In Smith v. Nicholson, 19 Vet. App. 63, 78, (2005) the Court then held that the pre-1999 and pre-June 13, 2003 versions of DC 6260 required the assignment of separate 10 percent evaluations for tinnitus in each ear. VA appealed this decision to the U.S. Court of Appeals for the Federal Circuit (Federal Circuit). The Federal Circuit subsequently reversed the Court's decision in Smith and affirmed VA's long-standing interpretation of the pre-June 13, 2003 DC 6260 as authorizing a single 10 percent evaluation for tinnitus, whether perceived as unilateral or bilateral. Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). The veteran is currently in receipt of the maximum schedular evaluation available for tinnitus, whether perceived in one ear or both ears, under both the pre-June 13, 2003 and current versions of DC 6260. The Board thus concludes that there is no legal basis for the veteran's entitlement to a higher initial evaluation for tinnitus. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The veteran does not assert that his tinnitus presents an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of regular schedular standards. Referral for extraschedular consideration under 38 C.F.R. § 3.321 is thus not indicated. ORDER Service connection for right ear hearing loss is denied. Service connection for fracture of ribs, left side, is denied. Service connection for left hip strain is denied. Service connection for sciatica to left hip is denied. Service connection for fracture of right fifth finger is denied. Service connection for a peptic ulcer is denied. Service connection for hypertension is denied. Service connection for chronic upper respiratory infection is denied. Service connection for renal failure is denied. Service connection for hyperlipidemia is denied. Service connection for gastroenteritis is denied. An initial evaluation in excess of 10 percent for tinnitus is denied. REMAND The veteran claims entitlement to service connection for disabilities of the left ankle, right thumb, left second and third toes, right elbow, left shoulder, left wrist, left knee and right hand and Guillain-Barré syndrome and entitlement to higher initial evaluations for diabetes mellitus, status post laparotomy and cholecystectomy, a left ear disability, hemorrhoids, a left fifth toe disability, hallux rigidus of the right great toe, laceration of left thumb, lumbar and cervical spine disabilities, GERD, coronary artery disease and a skin disability. Additional action is necessary before the Board decides these claims. As previously indicated, the VCAA provides that VA must notify a claimant of the evidence necessary to substantiate his claim and assist him in obtaining and fully developing all of the evidence relevant to his claim. In this case, with regard to the claims being remanded, VA has not yet provided the veteran adequate assistance; therefore, to proceed in adjudicating these claims would prejudice the veteran in the disposition thereof. Bernard v. Brown, 4 Vet. App. at 392-94. Under 38 U.S.C.A. § 5103A, VA's duty to assist includes pro vid ing a claimant a medical examination or obtaining a medical opinion whe n an examination or opinion is necessary to make a decision on a cla im. In thi s cas e, examinations in support of the claims being remanded are nec ess ary . The RO afforded the veteran examinations during the course of this app eal , but the rep ort s of these examinations are inadequate to decide these claims. Fir st, the rei n, no examiner commented on whether the veteran's current dis abi lit ies wer e related to his active service, during which he received tre atm ent for , or med ica l professionals noted ankle, thumb, toe, elbow, shoulder, wri st, kne e and han d complaints and Guillain-Barré syndrome. Second, since the vet era n und erw ent these examinations, in written statements dated November 2005 and Feb rua ry 200 8, the veteran's representative has requested that VA afford the vet era n add iti ona l examinations on the basis that approximately five years have pas sed sin ce the las t examinations. The Board agrees that additional examinations are nec ess ary giv en that initial evaluations are at issue and there must be suf fic ien t evi den ce of rec ord for the Board to determine whether staged ratings are app rop ria te. To so det erm ine , the evidence must be clear regarding the current level of imp air men t cau sed by the service-connected disabilities at issue in this Remand. Based on the foregoing, this case is REMANDED for the fol low ing act ion : 1. Arrange for the veteran to undergo a VA examination in support of his claims for service connection for disabilities of the left ankle, right thumb, left second and third toes, right elbow, left shoulder, left wrist, left knee and right hand. Forward the claims file to the examiner for review of all pertinent documents therein and ask the examiner to confirm in his written report that he conducted such a review. Following a thorough evaluation, during which all indicated tests are performed, the examiner should: a) diagnose all disabilities of the left ankle, right thumb, left second and third toes, right elbow, left shoulder, left wrist, left knee and right hand shown to exist; b) opine whether any disability preexisted service and, if so, whether it increased in disability in service; c) for any disability that did not preexist service, opine whether it is at least as likely as not related to the veteran's active service, including documented in-service ankle, thumb, toe, elbow, shoulder, wrist, knee and hand complaints; and d) provide detailed rationale, with specific references to the record, for the opinions provided. 2. Arrange for the veteran to undergo a VA examination in support of his claim for service connection for Guillain-Barré syndrome. Forward the claims file to the examiner for review of all pertinent documents therein and ask the examiner to confirm in his written report that he conducted such a review. Following a thorough evaluation, during which all indicated tests are performed, the examiner should: a) indicate whether the veteran has Guillain-Barré syndrome or residuals thereof, and if so, is it as least as likely as not related to service; and b) provide detailed rationale, with specific references to the record, for the opinion provided. 3. Arrange for the veteran to undergo a VA examination in support of his claims for higher initial evaluations for hallux rigidus of the right great toe, fracture of the first phalanx of the left fifth toe, lumbar spine and cervical spine disabilities. Forward the claims file to the examiner for review of all pertinent documents therein and ask the examiner to confirm in his written report that he conducted such a review. Following a thorough evaluation, during which all indicated tests are performed, the examiner should: a) identify all right great toe, left fifth toe, lumbar spine and cervical spine symptomatology, including, if appropriate, limitation of motion, ankylosis, abnormal gait, abnormal spinal contour, pain, tenderness, muscle spasm and guarding; b) identify the severity of the symptoms in terms of how often they manifest and to what degree; c) based on x-ray results, specifically indicate whether the veteran has arthritis of the right great toe, left fifth toe, lumbar spine and cervical spine; d) indicate whether the veteran has disc disease and, if so, identify the frequency and duration of any incapacitating episodes of such disease the veteran suffers during a 12 month period; e) consider whether the veteran's right great toe, left fifth toe, lumbar spine or cervical spine symptoms cause functional loss due to reduced or excessive excursion, decreased strength, speed, or endurance, or the absence of necessary structures, deformity, adhesion, and/or defective innervation and, if so, describe the extent of this loss during flare-ups or after repetitive use in terms of additional loss of motion beyond that which is observed clinically; f) indicate whether any reported pain is supported by adequate pathology and evidenced by visible behavior; g) identify any evidence of neuropathy or other nerve involvement due to the right great toe, left fifth toe, lumbar spine and cervical spine disabilities, to include reflex changes; h) describe the impact of each of the veteran's service-connected orthopedic disabilities on his daily activities and employability; and i) provide detailed rationale, with specific references to the record, for the opinions provided. 4. Arrange for the veteran to undergo a VA examination in support of his claims for higher initial evaluations for scars, residuals of a laparotomy and cholecystectomy and a left thumb laceration. Forward the claims file to the examiner for review of all pertinent documents therein and ask the examiner to confirm in his written report that he conducted such a review. Following a thorough evaluation, during which all indicated tests are performed, the examiner should: a) identify the nature of all scarring that results from the veteran's laparotomy and cholecystectomy and left thumb laceration, and the extent of areas affected in terms of square inches; b) specifically indicate whether the scarring limits the veteran's ability to function, is deep, or causes limited motion; c) identify all other residuals of the laparotomy and cholecystectomy and left thumb laceration; d) describe the severity of the symptoms in terms of how often they manifest and to what degree; e) describe the impact of the scarring on the veteran's daily activities and employability; and f) provide detailed rationale, with specific references to the record, for the opinions provided. 5. Arrange for the veteran to undergo a VA examination in support of his claim for a higher initial evaluation for a skin disability. Forward the claims file to the examiner for review of all pertinent documents therein and ask the examiner to confirm in his written report that he conducted such a review. Following a thorough evaluation, during which all indicated tests are performed, the examiner should: a) identify all skin symptomatology, including, if appropriate, scarring, exfoliation, exudation, itching, lesions, disfigurement, crusting, and systemic or nervous manifestations; b) identify the severity of the symptoms in terms of how often they manifest and to what degree; c) indicate whether the skin disability affects exposed or nonexposed areas and quantify by percentage all exposed areas affected; d) identify the percentage of the entire body affected by the skin disability; e) note all treatment for the disability, including, if appropriate, any systemic therapy, and identify the duration of such treatment during the prior 12-month period; f) describe the impact of the veteran's skin disability on his daily activities and employability; and f) provide detailed rationale, with specific references to the record, for the opinions provided. 6. Arrange for the veteran to undergo a VA examination in support of his claims for higher initial evaluations for digestive system disabilities. Forward the claims file to the examiner for review of all pertinent documents therein and ask the examiner to confirm in his written report that he conducted such a review. Following a thorough evaluation, during which all indicated tests are performed, the examiner should: a) identify all digestive system symptomatology, including, if appropriate, pain, vomiting, weight loss, hematemesis, melena, anemia, involuntary bowel movements, bleeding, hemorrhoids and fissures; b) identify the severity of the symptoms in terms of how often they manifest and to what degree; c) characterize the veteran's GERD as mild, moderate, moderately severe or severe; d) indicate whether and how often the veteran experiences incapacitating episodes of GERD and whether such episodes are productive of definite impairment of health; e) characterize any hemorrhoids as mild or moderate and indicate whether they are large, thrombotic, irreducible, inoperable, irremediable and/or involve excessive redundant tissue, persistent bleeding, anemia and/or fissures; f) describe the impact of each of the veteran's digestive system disabilities on his daily activities and employability; and g) provide detailed rationale, with specific references to the record, for the opinions provided. 7. Arrange for the veteran to undergo a VA examination in support of his claim for a higher initial evaluation for acoustic neuroma of the left ear. Forward the claims file to the examiner for review of all pertinent documents therein and ask the examiner to confirm in his written report that he conducted such a review. Following a thorough evaluation, during which all indicated tests are performed, the examiner should: a) identify all symptomatology associated with the acoustic neuroma of the cochlear nerve, left ear, and translabyrinth resection including, if appropriate, dizziness, staggering, vertigo, and cerebellar gait; b) identify the severity of the symptoms in terms of how often they manifest and to what degree; c) describe the impact of the veteran's left ear disability on his daily activities and employability; and d) provide detailed rationale, with specific references to the record, for the opinions provided. 8. Arrange for the veteran to undergo a VA examination in support of his claim for a higher initial evaluation for coronary artery disease. Forward the claims file to the examiner for review of all pertinent documents therein and ask the examiner to confirm in his written report that he conducted such a review. Following a thorough evaluation, during which all indicated tests are performed, the examiner should: a) identify all symptomatology associated with the veteran's coronary artery disease including, if appropriate, dyspnea, fatigue, angina, dizziness, and syncope; b) identify the severity of the symptoms in terms of how often they manifest and to what degree; c) indicate whether the coronary artery disease requires continuous medication; d) describe the impact of the veteran's coronary artery disease on his daily activities and employability; and e) provide detailed rationale, with specific references to the record, for the opinions provided. 9. Arrange for the veteran to undergo a VA examination in support of his claim for a higher initial evaluation for diabetes mellitus. Forward the claims file to the examiner for review of all pertinent documents therein and ask the examiner to confirm in his written report that he conducted such a review. Following a thorough evaluation, during which all indicated tests are performed, the examiner should: a) identify all symptomatology associated with the veteran's diabetes mellitus; b) identify the severity of the symptoms in terms of how often they manifest and to what degree; c) indicate whether the veteran's diabetes mellitus causes episodes of ketoacidosis or hypoglycemia requiring hospitalizations yearly or visits to a diabetic care provider monthly and if so, identify the number of hospitalizations and visits; d) describe the impact of the veteran's diabetes mellitus on his daily activities and employability; and e) provide detailed rationale, with specific references to the record, for the opinions provided. 10. Readjudicate the claims being remanded. For all denied claims, provide the veteran and his representative a supplemental statement of the case and an opportunity to respond thereto. Subject to current appellate procedure, return this case to the Board for further consideration. By this REMAND, the Board intimates no opinion as to the ultimate disposition of the claims being remanded. No action is required of the veteran unless he receives further notice. He does, however, have the right to submit additional evidence and argument on the remanded claims. Kutscherousky v. West, 12 Vet. App. 369, 372 (1999). The law requires that these claims be afforded expeditious treatment. 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 (West 2002) (Historical and Statutory Notes) (providing that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled expeditiously); see also VBA's Adjudication Procedure Manual, M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03 (directing the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court). ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs