Citation Nr: 1044080 Decision Date: 11/23/10 Archive Date: 12/01/10 DOCKET NO. 09-00 761 ) DATE ) ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Whether new and material evidence has been submitted to reopen the claim of service connection for a headache disorder. 2. Whether new and material evidence has been submitted to reopen the claim of service connection for tinnitus. 3. Entitlement to service connection for a headache disorder. 4. Entitlement to service connection for tinnitus. 5. Entitlement to service connection for sleep apnea. 6. Entitlement to service connection for hepatitis C. 7. Entitlement to service connection for a bilateral foot disorder. 8. Entitlement to service connection for a bilateral knee disorder. 9. Entitlement to service connection for a bilateral hip disorder. 10. Entitlement to service connection for a bilateral hand disorder. 11. Entitlement to service connection for bilateral hearing loss. 12. Entitlement to service connection for loss of vision. 13. Entitlement to service connection for a sinus disorder. 14. Entitlement to service connection for an anxiety disorder. 15. Entitlement to service connection for a depression disorder. 16. Entitlement to service connection for a lower back disorder. 17. Entitlement to service connection for an upper back disorder. 18. Entitlement to an evaluation in excess of 30 percent for the service-connected posttraumatic stress disorder (PTSD). 19. Entitlement to a total disability evaluation based upon individual unemployability by reason of service-connected disability (TDIU). REPRESENTATION Veteran represented by: Brooks S. McDaniel, Agent ATTORNEY FOR THE BOARD A. Nigam, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1969 to May 1973. This case comes before the Board of Veterans' Appeals (Board) on an appeal from a July 2008 rating decision and a December 2008 rating decision of the RO. Of preliminary importance, the claims of service connection for a headache disorder and for tinnitus had been previously denied in an unappealed rating decision in October 2001. The most recent attempt by the Veteran to reopen these claims was received by VA in December 2007. Although the RO adjudicated the claims on the merits in the July 2008 rating decision, the Board still is required to determine whether new and material evidence has been presented when a claim has been previously disallowed based upon the same factual basis. Barnett v. Brown, 83 F.3d 1380, 1384 (Fed. Cir. 1996). For this reason, the Board has characterized these matters as set forth on the title page. The Veteran was scheduled for a videoconference hearing with the Board in June 2010; however he failed to appear. The hearing notice was not returned as undeliverable, and no further communication was received from the Veteran or his agent regarding the hearing request or his failure to appear. Thus, the hearing request is deemed withdrawn. See 38 C.F.R. § 20.704 (2010). The issues of service connection for a headache disorder, hepatitis C, a bilateral foot disorder, a bilateral knee disorder, a bilateral hip disorder, a bilateral hand disorder, a bilateral hearing loss, an anxiety disorder, a depressive disorder, a lower back disorder, an upper back disorder, and TDIU rating are addressed in the REMAND portion of this document and are being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. An October 2001 rating decision denied the Veteran's claims of service connection for a headache disorder and for tinnitus; the Veteran was notified in writing of the RO's determination but did not appeal in a timely fashion. 2. The evidence submitted since the RO's October 2001 rating decision is new as it is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial, and relates to an unestablished fact necessary to substantiate the claims of service connection for a headache disorder and for tinnitus. 3. The evidence of record establishes that the Veteran engaged in combat with the enemy. 4. The currently demonstrated tinnitus is shown as likely as not to be due to the Veteran's documented exposure to acoustic trauma during active service in the Republic of Vietnam. 5. The Veteran did not manifest complaints or findings of sleep apnea in service or for many years thereafter. 6. No current vision disorder is demonstrated, and no vision disorder is otherwise related to service. 7. No current sinus disorder is demonstrated, and no sinus disorder is otherwise related to service. 8. The service-connected PTSD is shown to have been manifested by a level of disablement that more closely resembles one of occupational and social impairment, with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks, weekly or less often, chronic impairment, and mild memory loss. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the claim of connection for a headache disorder. 38 U.S.C.A. § 5108 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.104, 3.156, 3.159 (2010). 2. New and material evidence has been received to reopen the claim of connection for tinnitus. 38 U.S.C.A. § 5108 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.104, 3.156, 3.159 (2010). 3. By extending the benefit of the doubt to the Veteran, his disability manifested by tinnitus is due to disease or injury that was incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 4. The Veteran does not have a disability manifested by sleep apnea due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 5. The Veteran does have a disability manifested by an acquired loss of vision due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 6. The Veteran does not have a sinus disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 7. The criteria for the assignment of an evaluation in excess of 30 percent for the service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.130 including Diagnostic Code (DC) 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act (VCAA) VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. In this case, notice fulfilling the requirements of 38 C.F.R. § 3.159(b) was furnished to the Veteran in the February 2008 and July 2008 letters. Specifically, in these letters the Veteran was notified of VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The United States Court of Appeals for Veterans Claims (Court) has also held, in the context of a claim to reopen on the basis of new and material evidence, that VA must look at the bases for the denial in the prior decision and to respond with a notice letter that describes the type of evidence and information that would be necessary to substantiate that element or elements required to establish service connection that were found insufficient in the previous denial. Kent v. Nicholson, 20 Vet. App. 1 (2006). Here, the February 2008 letter indicated both that certain claims had previously been denied in the RO decisions, as described in greater detail below, and that evidence would be needed to substantiate a link between these disorders and service. The Board finds such action to be fully adequate in view of Kent. The claims were readjudicated in March 2009. As this course of action has corrected any initial notice errors, there is no prejudice to the Veteran. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). VA has also fulfilled its duty to assist in obtaining the identified and available evidence needed to substantiate the claim adjudicated in this decision. The RO has either obtained, or made sufficient efforts to obtain, records corresponding to all treatment described by the Veteran. Specifically, the Veteran has been afforded VA examinations to address the nature and etiology of his claimed disorders, as well as to address the nature and severity of his service-connected disability. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Hence, the Board is satisfied that all reasonable efforts to develop the record have been made with respect to the claims. As discussed, the Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process, identifying pertinent medical evidence and submitting evidence. Thus, the Veteran has been provided with a meaningful opportunity to participate in the claims process and has done so. Any defect in the sequence of events or content of the notice is not shown to have a prejudicial effect on the case or otherwise to cause injury to the Veteran. Therefore, any such defect is harmless and does not prohibit consideration of the matters addressed hereinbelow. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. General Legal Criteria A. New and Material Evidence Generally, a claim which has been denied in an unappealed RO decision or an unappealed Board decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c) (West 2002 & Supp. 2009). However, with exception, 38 U.S.C.A. § 5108 provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. The Board must consider the question of whether new and material evidence has been received because it goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim de novo. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no such evidence has been offered, that is where the analysis must end, and what the RO may have determined in that regard is irrelevant. Barnett, supra. Further analysis, beyond consideration of whether the evidence received is new and material is neither required nor permitted. Id. at 1384. See also Butler v. Brown, 9 Vet. App. 167, 171 (1996). "New" evidence is defined as existing evidence not previously submitted to agency decision makers. "Material" evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held, however, that evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343 (2000). B. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 2002). Service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2010). To establish a service connection for an injury, a veteran is required to show (1) medical evidence of a current disability, (2) medical or lay evidence of in-service incurrence or aggravation of an injury, and (3) medical evidence of a nexus between the claimed in-service injury and the present disability. Dalton v. Nicholson, 21 Vet. App. 23, 36 (2007). In cases where the veteran cannot establish some of these elements, a veteran can instead establish continuity of symptomatology. 38 C.F.R. § 3.303(b); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). To establish continuity of symptomatology, the a veteran is required to show "(1) that a condition was 'noted' during service, (2) evidence of postservice continuity of the same symptomatology, and (3) medical or lay evidence of a nexus between the present disability and the postservice symptomatology." Barr, 21 Vet. App. at 307. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. 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. C. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The question of an extraschedular rating is a component of a claim for an increased rating. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such 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 the regular schedular standards." Id. Therefore, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent period of hospitalizations as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2010). D. Standard of Review The record shows that the Veteran served in the Republic of Vietnam from May 1970 to November 1971. His principal duty assignments included those of rifleman, aircraft maintenance apprentice and helicopter repairman. Moreover, the service personnel records show that he was awarded two Bronze Service Stars to his Vietnam service Medal, the Army Commendation Medal, the Good Conduct Medal, the Republic of Vietnam Campaign Medal, a Sharpshooter Badge, the National Defense Service medal, a Parachute Badge, the Vietnam Service Medal, and the Combat Infantryman Badge. It must be noted that as a combat veteran, the Veteran is entitled to the application of 38 U.S.C.A. § 1154(b). Section 1154(b) does not create a statutory presumption that a combat veteran's alleged disease or injury is service connected. Collette v. Brown, 82 F.3d 389, 392 (Fed. Cir. 1996). Rather, it aids the combat veteran by relaxing the adjudicative evidentiary requirements for determining what happened in service. Id. Section 1154(b) addresses the combat veteran's ability to allege that an event occurred in service while engaging in combat. See Beausoleil v. Brown, 8 Vet. App. 459, 464 (1996). That section, however, does not address the questions of either current disability or nexus to service, both of which competent medical evidence is generally required. Id. citing Caluza v. Brown, 7 Vet. App. 498, 507 (1995). As the Combat Infantryman Badge denotes combat participation, the Board concedes that the Veteran is entitled to the application of 38 U.S.C.A. § 1154(b). The Board's analysis will focus specifically the evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. III. Specific Legal Criteria The Veteran's PTSD is currently evaluated as 30 percent disabling under 38 C.F.R. § 4.130, DC 9411 (2010). This diagnostic code provides: 50% Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; 30% Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often) chronic impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9411 (2010). Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV, for rating purposes] (2010). IV. Analysis A. New and Material Evidence In addressing whether new and material evidence has been submitted to reopen the claims of service connection for a headache disorder and for tinnitus, the RO in a rating decision in October 2001 denied these claims. The Veteran was notified in writing of this action and apprised of his appellate rights, but did not appeal in a timely manner. 38 U.S.C.A. § 7105. The evidence of record at the time of the RO's October 2001 rating action included the Veteran's service treatment records, private treatment records, and a VA PTSD examination report. In a VA Form 21-4138, Statement in Support of Claim, received in December 2007, the Veteran requested that his claims for service connection for a headache disorder and for tinnitus be reopened. The evidence added to the record since the October 2001 RO rating decision includes various VA treatment records and probative VA examination reports. In addition to new medical treatment records, the new evidence includes statements in support of the claim from the Veteran regarding his claimed disorders. Based on a careful review of the record, the Board finds the evidence added since the October 2001 rating decision regarding the claims of service connection for a headache disorder and tinnitus provides a more complete picture of the circumstances surrounding the origins of the claimed headache disorder and tinnitus, see Hodge v. West, 115 F.3d 1356, 1363 (Fed. Cir. 1998). Thus, the evidence is found to be new and material for the purpose of reopening the claims. Specifically, the VA treatment records, VA examination reports, and the Veteran's statements are new, in that they are evidence that has not been considered by the RO. They are also material, in that they relate to an unestablished fact necessary to establish the claim. Therefore, this evidence is new and material for the purpose of opening the claims. B. Service Connection With respect to the now reopened claim of service connection for tinnitus, the Veteran asserts that he currently suffers from tinnitus as the result of loud noise exposure incident to his combat duties in service. In this case, the Veteran's assertions of experiencing tinnitus since his service are competent. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). See also 38 C.F.R. § 3.159(a)(2) (2010). In this regard, his DD Form 214, Certificate of Release or Discharge from Active Duty, reveals that his military occupational specialty (MOS) was as a helicopter repairman. Given the circumstances of the Veteran's service, in-service noise exposure is conceded. 38 U.S.C.A. § 1154 (b). Significantly, a service treatment record, dated in February 1973, shows findings of tinnitus on examination. Notably, a VA treatment record, dated in September 2002 indicates findings of acute hearing changes and tinnitus. The Board notes that the Veteran is competent to testify as to observable symptoms such as ringing in his ears, and tinnitus is the type of is the type of disorder associated with symptoms capable of lay observation. See Charles v. Principi, 16 Vet. App. 370 (2002); Falzone v. Brown, 8 Vet. App. 398, 403 (1995)). Based on a thorough review of the record, and in light the Veteran's credible lay statements, the Board finds that evidence is in relative equipoise in showing that the current tinnitus as likely as not had its clinical onset as the result of exposure to extremely increased noise levels during service. See Gilbert, 1 Vet. App. at 55. With respect to the claim of service connection for sleep apnea, the Veteran generally asserts that his current sleep apnea is related to his active service. The Board has carefully reviewed the evidence of record, but finds that the preponderance of the evidence is against the claim of service connection for sleep apnea. Significantly, the service treatment records are entirely negative for findings of or treatment for sleep apnea. Moreover, sleep apnea was not shown in treatment records until many years after the Veteran was discharged from service. This is strong evidence against a finding of any continuity of symptomatology. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000). In this regard, the first notation of sleep apnea in the record was in a VA PTSD examination report dated in August 2001. In a December 2003 VA examination, the Veteran reported that he had been treated for the past 10 years for his sleep apnea with Trazodone and a CPAP machine. However, his lay statements are negative for any nexus information that would serve to establish a continuity of symptomatology linking the currently demonstrated manifestations due to sleep apnea to the Veteran's period of active service. In addressing the statutory requirements of 38 C.F.R. § 3.159(c)(4), the Board notes that, in a claim for disability compensation, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. A medical examination or medical opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but: (A) contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of disability; (B) establishes that the Veteran suffered an event, injury or disease in service, or has a disease or symptoms of a disease listed in § 3.309, § 3.313, § 3.316, and § 3.317 manifesting during an applicable presumptive period provided the claimant has the required service or triggering event to qualify for that presumption; and (C) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service or with another service-connected disability. Here, on review, the Board also finds no competent evidence to support the Veteran's lay assertions that his current sleep apnea had its clinical onset during his service. As noted, his service treatment records are negative for complaints or findings to any sleep apnea, and the record fails to indicate treatment for sleep apnea until 2001. Accordingly, without an identified antecedent event during service, VA examination would serve no useful purpose as any opinion would be based on speculation. With respect to the claims of service connection for vision and sinus disorders, the Veteran generally is asserting that he currently experiences chronic vision and sinus problems that are related to his active service. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claims of service connection for an acquired loss of visual acuity or for a sinus disorder. Notably, the service treatment records show no complaints or findings for a loss of vision or sinus pathology. In fact, a February 1973 service treatment record explicitly showed negative findings for chronic sinusitis. Moreover, there is no medical evidence of record showing that the Veteran is being actively treated for any loss of vision or sinus disorder post following service. In fact, a December 2003 VA general examination, provided in conjunction with this appeal, show normal findings for the eyes, non-icteric, as well as normal findings for the sinuses. Moreover, VA treatment records, dated from 2002 to 2008 are negative for findings of or treatment for any vision or sinus pathology. The Board finds that the December 2003 VA examiner's findings constitute probative and dispositive evidence on the current medical condition question. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. § 1110. Thus, where, as here, medical evidence does not establish a current disability upon which to predicate a grant of service connection, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer, 3 Vet. App. at 225. In the instant case, the claims of service connection for a vision disorder and a sinus disorder must be denied because the first essential criterion for a grant of service connection, evidence of a current disability upon which to predicate a grant of service connection, has not been met. The Board recognizes that the requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, neither the Veteran nor his representative has presented or identified any existing medical opinion showing findings of any vision or sinus disorders. Overall, the only evidence of record supporting the Veteran's claims for service connection are his own lay statements including descriptions of his claimed symptomatology. The Board must assess the competency and credibility of lay statements regarding in-service or continuous postservice symptomatology. As to this, a layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998); see also 38 C.F.R. § 3.159(a)(1) and (2) defining, respectively, competent medical and lay evidence. Where the determinative issue involves causation or a diagnosis, there must be competent evidence and, generally, lay statements are not competent evidence. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, lay evidence can be competent to establish a diagnosis when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), or (2) the layperson is reporting a contemporaneous medical diagnosis (but see Robinette v. Brown, 8 Vet. App. 69, 77 (1995) when the underlying medical nature of evidence has been significantly diluted, as in the connection between a lay account of past medical information, and filtered through layman's sensibilities, such evidence is too attenuated and inherently unreliable to constitute medical evidence) or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Moreover, the information recorded by the medical examiner is unenhanced by any additional medical comment, and thus not adding any medico-evidentiary value to the lay history through medical expertise, does not constitute competent medical evidence. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995). In the first circumstance, identification of a medical condition, there is a two-step analysis, the first is competence and the second is credibility. Robinson v. Shinseki, 2008-7096 (Fed. Cir. March 3, 2009) (not selected for publication); 312 Fed.Appx. 336, 2009 WL 524737 (C.A.Fed.). In the first step, competency of lay evidence, it must be determined whether the disability is capable of lay observation, if so, then lay evidence thereof is not a medical determination requiring medical evidence; rather, it can be established by competent lay evidence. Jandreau, Id.; Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); see 38 C.F.R. § 3.159(a)(2). If not, then competent medical evidence is required. If lay evidence is competent, then the second step is to assess credibility by weighing the pertinent lay evidence against the other evidence-including in-service records documenting in- service injury or disability, if any. Robinson, Id. The credibility of lay statements may not be refuted solely by the absence of corroborating medical evidence, but this is a factor. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Other factors are the lapse of time in recollecting events, prior conflicting statements, consistency with other statements and evidence, internal consistency, facial plausibility, bias, self- interest, the earliest time at which corroborating lay or medical evidence is first shown, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). Notably, beyond the Veteran's initial statement generally claiming service connection for sleep apnea, a vision disorder, and a sinus disorder (see VA Form 21-4138, Statement in Support of Claim, received in December 2007), he has not provided additional lay statements that address the continuity of symptomatology of his claimed disorders from the time of service until the present. Although the Veteran is deemed competent and credible to describe symptoms of sleep apnea, vision pathology and sinus pathology that he relates to his active service, as these particular symptoms are capable of lay observation, he is not shown to possess any training, expertise or credentials in the field of medicine to be able to comment meaningfully on the clinical diagnosis of a vision or a sinus disorder, or on the etiology of his current sleep apnea. Accordingly, his lay assertions must be addressed in terms of the clinical findings identified by the December 2003 VA examination and based upon a detailed assessment of various diagnostic tests. Therefore, for these reasons, the Board finds that the preponderance of the evidence is against the claims of service connection for sleep apnea, a vision disorder, and a sinus disorder. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. See Gilbert, 1 Vet. App. at 55. C. Increased Ratings By way of procedural background, in an October 2001 rating decision, the RO granted service connection for PTSD, and a 30 percent evaluation was assigned, effective from February 8, 1999. The Veteran filed his current claim for an increased rating in December 2007. The Veteran asserts that his PTSD warrants an increased rating due to symptoms that include sleep disturbance, chronic anxiety attacks, inability to obtain or sustain employment, nightmares, flashbacks, feelings of impatience and irritability and chronic depression. In the instant case, the Board finds that the service-connected disability picture does not meet the criteria for a rating higher than 30 percent under DC 9411. In this regard, the VA treatment records, dated from March 2007 to December 2008, show treatment for chronic PTSD, anxiety, depression, excessive sleep, along with diagnoses of major depression, PTSD and adult attention-deficit disorder, and GAF scores of 55. In conjunction with the current appeal, at a VA PTSD examination in May 2008, the Veteran denied having close friendships or social relationships outside of those with his mother and reported spending most of his time by himself. The Veteran noted doing grocery shopping for himself, going to church, restaurants and flea markets, and enjoying reading and watching television, but lacked a number of other leisure pursuits, primarily because of financial and health restrictions and not due to lack of desire. He denied substance abuse problems, violent or assaultive behavior, or suicide attempts. The examiner noted that many of the treatment records since the last examination reflected that the PTSD symptomatology was relatively stable and under control or improved. Moreover, the Veteran's depression was noted to fluctuate and was primarily related to his financial difficulties. On mental status examination, the examiner observed that the Veteran presented with a restricted affect, and his mood appeared dysphoric and anxious. The examiner noted no impairment of thought processing or communication or delusions or hallucinations. The Veteran had appropriate eye contact and behavior, and adequately maintained his personal hygiene and performed the basic activities of living. He denied having suicidal or homicidal ideation and was oriented, although he complained of some short-term memory loss, which the examiner believed had to do with difficulty with attention or distractibility. He reported being off his attention-deficit hyperactivity disorder medication, which the examiner noted might be a factor with his symptoms. The VA examiner observed no obsessive compulsive behavior and added that speech within normal limits. The VA examiner noted that, at the time of the last VA examination, the Veteran reported experiencing panic attacks two to three times per week. However, during the current examination, he noted having had only two or three panic attacks since his last examination, four and a half years ago. The Veteran reported ongoing problems with depressed mood, stating that he was seldom happy and was depressed and anxious the majority of the time. He described some periods of self- criticism and low self-worth and added that he occasionally cried and felt helpless. The Veteran endorsed symptoms of anxiety, which the examiner attributed to significant financial concerns, health problems, and his mother's health problems. The examiner observed adequate impulse control without severe anger outbursts, but he complained of sleep disturbance, which the examiner attributed to possible sleep apnea. The examiner indicated that the Veteran met the DSM-IV stressor criteria, to include experiencing combat-related nightmares between once a week and once a month, almost daily intrusive memories of wartime experiences, avoidance, limited social interactions, hypervigilance, irritability, frustration, drowsiness, hyper-startle response to loud sudden noises, and poor concentration. The Veteran was diagnosed with PTSD, major depressive disorder, anxiety disorder not otherwise specified, and attention deficit disorder, and was assigned a GAF score of 56 for his diagnosed mental health pathology overall. The examiner opined that the Veteran continues to have PTSD symptomatology with his depressed mood and anxiety seeming to be largely related to his health problems and to the health problems of his mother. The examiner attributed the Veteran's tiredness and drowsiness to his sleep apnea and his concentration difficulties to his attention-deficit, hyperactivity disorder. The Board has reviewed the entire record and finds that the criteria for an evaluation in excess of 30 percent have not been met. The pertinent medical evidence collectively reflects that, during the time frame in question, the service-connected PTSD was characterized, primarily, by depressed mood, anxiety, suspiciousness, monthly panic attacks, chronic sleep impairment, and mild memory loss. The Board finds that these symptoms equate with occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks as contemplated by the criteria for a 30 percent rating. Moreover, the May 2008 VA PTSD examiner related the Veteran's depressed mood, anxiety, chronic sleep impairment, and difficulties in concentrating to other factors unrelated to his service-connected PTSD. In addition, the assigned GAF scores of 55 and 56 do not provide a basis for assigning an initial rating in excess of 30 percent for the service-connected PTSD. As noted, GAF scores ranging from 51 to 60 are reflective of no more than moderate symptoms overall and comport with social and occupational functioning, consistent with a 30 percent rating. However, as noted, the GAF scores assigned in a case, like one examiner's assessment of the severity of a condition, alone are not dispositive of the rating question; rather, they constitute probative evidence that must considered in light of all the other evidence referable to the service-connected disability picture. See 38 C.F.R. § 4.126(a). Overall, the evidence does not show that the service-connected PTSD has been productive of occupation and social impairment that would meet or more nearly approximate the criteria for the 50 percent rating. This did not include difficulty in establishing and maintaining effective social relationships, disturbances of motivation and mood, or difficulty with memory. In short, the Board finds that the evidence is indicative of no greater impairment than that contemplated by the initial 30 percent rating assigned. As the criteria for the next higher, 50 percent, rating were not met during this period, it follows that the criteria for the higher 70 percent and 100 percent rating likewise are not met for the period of the appeal. The Board has considered the provisions of 38 C.F.R. § 3.321(b)(1), but finds the service-connected picture is not so unusual or exceptional as to obviate the application of the established rating criteria. The service-connected PTSD also is not shown to cause marked interference with employment beyond that contemplated by the assigned evaluation or require periods of hospitalization during the pendency of this appeal. Although the May 2008 VA examiner noted that the Veteran was currently unemployed, despite finishing his degree, the Veteran added that he was not currently looking for work and had completed three degrees in electronics and computers and done well on his school examinations. Significantly, a statement received in August 2008, which accompanied the Veteran's resume, revealed that the reasons for leaving his prior employment included a sleeping disorder that caused him to be tired and sleepy during the day, a job reduction or lay off, his physical health problems, the position was a temporary job and was too far to drive without spending too much money on gas, his moving to a different state, his having no steady work, his achieving the maximum salary and receiving marginal wages and aggravating a knee injury, his fear of contracting diseases while working as an emergency medical technician, his inability to obtain the necessary work and being under-qualified for the job, and his efforts to obtain other employment. Notably, the Veteran did not list symptoms associated with his diagnosis of PTSD as a reason for leaving any of his prior jobs. As such, the Board is not required to remand this matter to the RO for referral actions outlined in 38 C.F.R. § 3.321(b)(1), which concern the assignment of extra- schedular evaluations in "exceptional" cases. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 94-95 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Thun v. Peake, 22 Vet. App. 111, 115 (2008). Further, the Board acknowledges the Court's recent holding that a request for a TDIU rating is not a separate claim for benefits but, rather is part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Crucially, the Veteran has asserted a separate claim for a TDIU rating, which is discussed in the remand section of this decision; hence, the matter of individual unemployability caused by his service-connected PTSD is still pending. Consequently, the Board finds that discussion of a TDIU rating must be deferred at this time. Finally, the Board has considered whether "staged" ratings are appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The record, however, does not support assigning different percentage disability ratings during the period in question. ORDER New and material evidence has been received to reopen the claim of service connection for a headache disorder; the appeal to this extent is allowed and is subject to development as discussed hereinbelow. New and material evidence has been received to reopen the claim of service connection for tinnitus; the appeal to this extent is allowed. Service connection for tinnitus is granted. Service connection for sleep apnea is denied. Service connection for a loss of vision is denied. Service connection for a sinus disorder is denied. An increased evaluation in excess of 30 percent for the service- connected PTSD is denied. REMAND As noted, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 2002). Service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2010). Every person employed in the active military, naval, or air service shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); 38 U.S.C.A. §§ 1111, 1137 (West 2002). Service connection can be established for a disability which preexisted service, but was permanently aggravated thereby. A pre-existing disease or injury will be found to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a) (2010). With respect to the claims of service connection for a headache disorder, a bilateral hip disorder, a right hand disorder, anxiety, depression, a lower back disorder, and an upper back disorder, the Veteran asserts that these disorders are the result of injuries sustained and illness incurred during his active service. The Board concedes that pre-service private treatment records show treatment for multiple contusions of the scalp, right hand, right buttock, neck and back strain, and cerebral concussion as the result of an automotive accident that took place on May 5, 1969. A private physician opined that the Veteran made a satisfactory recovery from his injuries without permanent disability effect, although he was observed to still complain of a certain amount of aching discomfort in the neck and upper back as well as the occasional headache. Significantly, the Report of Medical History accompanying the Veteran's service induction examination, dated in August 1969, showed "checked boxes" for "history of head injury," for "nervous trouble of any sort," and for "depression or excessive worry." Moreover, the service treatment records showed findings of fatigue, affect depressed and constricted with thought disorder, reactive depression, pain in the right hip present on and off for 5 years, headaches following whiplash injury two years ago, neck pain with moderate spasm of neck, right knee injury, pain in the right hip for over four to five years, and upper back pain. The service treatment records also show treatment for a cut in the palm of the left hand, boot limitations due to tendo-achilles and extensors manifestations, pain in the right foot, injury to the right knee, injury to the great toe on the right foot, a sore toe, cut on the top of the head from a spinning rotary blade, and an injury to the foot after stepping on a rusty nail. A December 2003 VA examination report noted diagnoses of chronic low back strain with mild osteoarthritis, and joint arthralgias of the hips, knees, etc. The examiner failed to provide an opinion as to the nature and etiology of these disorders. Given this history, the Board finds it necessary to obtain a medical opinion to determine the nature and likely etiology of the claimed headache, right hip, right hand, anxiety, depression, lower back, and upper back disorders. See 38 C.F.R. § 3.159(c)(4) (2010). With respect to the claim of service connection for hepatitis C, the Veteran reports contracting hepatitis C as the result of exposure to the virus while serving in combat in Vietnam. However, this lay statement does not relieve the requirement that there be objective medical evidence that addresses whether a nexus exists between any claimed in-service exposure and the current disability. The Board notes that the Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Lay statements may also be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Additionally, the December 2003 VA examination report conducted in conjunction with this appeal, did not provide an opinion regarding the likely etiology of the claimed hepatitis C. Thus, the Board finds that a medical examination is necessary for this purpose. See 38 C.F.R. § 3.159(c)(4) (2010); McLendon v. Nicholson, 20 Vet App. 79, 81 (2006); see also Duenas v. Principi, 18 Vet. App. 512 (2004). Moreover, as noted service treatment records show findings of injury to the knees, feet, and hands, as the Veteran has been diagnosed with various joint arthralgias, and as a nexus opinion is not currently of record regarding these disorders, the Board finds that a VA examination is also warranted to determine the nature and likely etiology of the claimed bilateral knee, foot and hand disorders. Further, regarding the hearing loss, the Veteran reports suffering from hearing problems as the result of noise exposure in service. As noted, the service treatment records do show findings of tinnitus. For the purposes of applying the laws administered by the VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000 and 4,000 Hertz is 40 decibels or greater; or when the thresholds for at least three of these frequencies 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 (2010). However, the absence of in-service evidence of hearing loss is not fatal to the claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability (i.e., one meeting the requirements of section 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). In this case, the Veteran's assertion of experiencing hearing loss since his service is competent and is credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). See also 38 C.F.R. § 3.159(a)(2) (2010). In this regard, his DD Form 214, Certificate of Release or Discharge from Active Duty, reveals that his military occupational specialty (MOS) was as a helicopter repairman. Given the circumstances of the Veteran's service, to include combat service, in-service noise exposure is conceded. The provisions of VCAA, codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the Court is applicable to this appeal. Specifically, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. See 38 C.F.R. § 3.159(c)(4) (2010). With respect to the claim for a TDIU rating, a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, received in August 2008, shows that the Veteran was last employed in February 2000 as an electronic technician and was longer able to secure or follow any substantially gainful occupation due to his service-connected PTSD, and to his nonservice-connected anxiety and depression. A TDIU rating may be assigned when there is a single disability ratable at 60 percent or more, and the disabled person is unable to secure or follow a substantially gainful occupation. For the above purpose of one 60 percent disability, the following will be considered as one disability: (1) disabilities of one or both lower extremities, including the bilateral factor, (2) disabilities resulting from common etiology, or (3) disabilities affecting a single body system, e.g., orthopedic. See 38 C.F.R. § 4.16(a) (2010). A TDIU rating may be assigned when a schedular rating is less than total if, when there are two or more disabilities, at least one disability is ratable at 40 percent or more, and any additional disabilities result in a combined rating of 70 percent or more, and the disabled person is unable to secure or follow a substantially gainful occupation. See 38 C.F.R. § 4.16(a) (2010). A TDIU rating may also be assigned on an extraschedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). In determining whether the veteran is entitled to a TDIU rating, neither his nonservice-connected disabilities nor his advanced age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). A claim for a TDIU is, in essence, a claim for an increased rating. Norris v. West, 12 Vet. App. 413, 420 (1999). A TDIU claim is an alternate way to obtain a total disability rating without recourse to a 100 percent evaluation under the rating schedule. See, e.g., Parker v. Brown, 7 Vet. App. 116, 118 (1994). Notably, the record includes VA examination reports, dated in August 2001, December 2003, and May 2008 that assessed the impact of the Veteran's service-connected PTSD, type II diabetes mellitus, laceration on the top of the head, and laceration of the left palm had had upon his activities of daily living and on his employability. However, the VA examiners failed to offer an opinion as to whether, without regard to age or the impact of any nonservice- connected disabilities, it was at least as likely as not that the service-connected disabilities, either separately or in combination, preclude him from securing and following a substantially gainful occupation consistent with his education attainments and previous occupational experience. Moreover, in TDIU claims, the Court has held that the duty to assist requires that VA obtain an examination, which includes an opinion on what effect the Veteran's service-connected disabilities have on his ability to work. 38 U.S.C.A. § 5107(a) (West 2002 & Supp. 2009); Friscia v. Brown, 7 Vet. App. 294, 297 (1994); 38 C.F.R. §§ 3.103(a), 3.326, 3.327, 4.16(a) (2010). As noted, a review of the claims file does include such an opinion with respect to the TDIU claim. However, in light of the unresolved issues of service connection for a number of claimed disorders, which might impact on the Veteran's combined rating evaluation, the Board finds that it is necessary to obtain a new examination regarding his employability. Accordingly, VA examination is warranted in order to obtain a new opinion concerning the Veteran's employability. The Board reminds the Veteran that the duty to assist is not a one-way street, and that he has a duty to cooperate, to include reporting for examination. 38 C.F.R. §§ 3.326, 3.327, 3.655 (b) (2009); see also Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). He is advised that he has an obligation to assist VA in the development of his claim, and that failure to do so may result in an adverse decision. Prior to arranging for the Veteran to undergo these examinations, VA should obtain and associate with the claims file all outstanding VA medical records. The only VA treatment records contained within the claims file are from the Salem, Virginia VA Medical Center (VAMC) dated to December 2008. He appears to continue to receive ongoing treatment from this facility. As such, the RO should seek to obtain any treatment records from December 2008 to the present. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Accordingly, these remaining matter certified on appeal are REMANDED to the RO for the following action: 1. The RO should take appropriate steps to contact the Veteran and request that he furnish the names, addresses, and dates of treatment of all medical providers from whom he has received treatment for his claimed headache disorder, hip disorder, hand disorder, anxiety disorder, depression disorder, lower back disorder, upper back disorder, bilateral hearing loss, hepatitis C, bilateral knee disorder, bilateral foot disorder, and bilateral hand disorder. In particular, the RO should seek to obtain treatment records from the Salem VAMC, from December 2008 to the present. After securing the necessary authorizations for release of this information, the RO should seek to obtain copies of all treatment records referred to by the Veteran not already on file. 2. The RO should schedule the Veteran for various VA examinations to determine the nature and likely etiology of the claimed headache, hip, hand, anxiety, depression, lower back, and upper back disorders. Prior to examining the Veteran, the examiner(s) must review the entire claims file, including a complete copy of this remand. All necessary diagnostic testing should be performed, and all clinical findings should be reported in detail. Specifically, the examiner(s) should opine as to whether it is as likely as not (e.g., a 50 percent or greater probability) that the Veteran has a headache disorder, a hip, a hand, an anxiety, a depression, a lower back, or an upper back disability that is due to an event or incident of his period of active service. Finally, the examiner should set forth in the examination report all findings and a complete rationale for any conclusions reached. 3. Next, the RO should schedule the Veteran for VA examinations to determine the nature and likely etiology of the claimed hepatitis C, bilateral knee, bilateral feet, bilateral hand, and bilateral hearing disorders. The Veteran's claims file must be reviewed by the examiner(s). All indicated tests should be performed and all findings should be reported in detail. The examiner(s) should provide an opinion as to whether it is at least as likely as not (a 50 percent or more probability) that any current hearing loss is due noise exposure or another event of his active service, and whether any current knee, foot or hand disability that is due to an event or incident of his active service. The examiner(s) should set forth the complete rationale for all opinions expressed and conclusions reached. 4. Following completion of all indicated development, the RO should readjudicate these remaining claims in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his agent should be furnished with a fully responsive Supplemental Statement of the Case (SSOC) and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs