Citation Nr: 1125024 Decision Date: 07/01/11 Archive Date: 07/14/11 DOCKET NO. 06-10 266 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for hearing loss of the right ear. 2. Entitlement to service connection for chronic dental disorder manifested by tooth pain. 3. Entitlement to service connection for bilateral foot disability manifested by pain. 4. Entitlement to service connection for residuals of a cardiac arrest. 5. Entitlement to service connection for residuals of pneumonia, manifested by a pulmonary granuloma. 6. Entitlement to service connection for a psychiatric disorder, claimed as adjustment disorder, depression and posttraumatic stress disorder (PTSD). 7. Entitlement to service connection for gastroesophageal disorder (GERD). 8. Entitlement to an initial disability rating in excess of 30 percent for nephrolithiasis with recurrent urinary tract infections and voiding problems. 9. Entitlement to an initial disability rating in excess of 10 percent for residuals of low back injury, status post fusion L4-S1 with degenerative disc disease. 10. Entitlement to an initial compensable disability rating for left ear hearing loss. 11. Entitlement to an initial compensable disability rating for residuals of internal hemorrhoids, status post multiple bandings. 12. Entitlement to an initial compensable disability rating for residuals of a perianal abscess and fistula, status post fistulectomy, with pruritis ani. 13. Entitlement to an initial compensable disability rating for erectile dysfunction associated with low back injury and hypertension. 14. Entitlement to an initial compensable disability rating for residuals of folliculitis, seborrhic dermatitis, and lichen simplex chronicus of the scalp. 15. Entitlement to an initial compensable disability rating for varicose veins of the right foot. 16. Entitlement to an initial compensable disability rating for varicose veins of the left foot. 17. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.R. Bryant, Counsel INTRODUCTION The Veteran had active service from November 1980 to February 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions in April 2004 and November 2008 by the above-referenced Regional Office (RO). In October 2010, the Veteran testified before the undersigned Veterans Law Judge in Atlanta, Georgia; a transcript of that hearing is of record. The issues of entitlement to service connection for GERD and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. At no time during the current appeal has the Veteran exhibited a right ear hearing loss disability as defined by VA regulation. 2. The Veteran's complaints of tooth pain do not represent a finding of a separate dental disorder, inasmuch as they are not productive of chronic impairment and have been determined by the evidence of record to be part and parcel of his already service-connected sinusitis. 3. Competent evidence does not show a chronic bilateral foot disability, to include arthritis, at any time during the pendency of the appeal. 4. The Veteran's in-service episode of cardiac arrest was acute and transitory, and chronic disabling residuals were not then present, nor is there competent medical evidence of current chronic residuals related to the in-service cardiac arrest. 5. The Veteran's in-service bouts of pneumonia were acute and transitory with no chronic disabling residuals; the current finding of pulmonary granuloma alone does not constitute a disability for which VA compensation benefits may be awarded. 6. In resolving doubt in the Veteran's favor, his chronic adjustment disorder with depression is reasonably shown to have had its onset during military service. 7. The Veteran's service-connected recurrent kidney stones do not result in renal dysfunction with constant albuminuria with some edema, definite decrease in kidney function, or hypertension that is at least 40 percent disabling, i.e., with diastolic pressure predominately 120 or more. He does not have a disability requiring the wearing of absorbent materials which must be changed 2-4 times per day or resulting in a daytime voiding interval of less than one hour or awakening to void five or more times per night. 8. The Veteran's service-connected lumbar degenerative disc disease is manifested by full or nearly full forward lumbar spine flexion, and a combined range of motion greater than 120 degrees. He does not have muscle spasm, guarding, localized tenderness, or a vertebral body fracture. There is also no evidence of ankylosis, chronic neurologic disability manifestations, or incapacitating episodes of intervertebral disc syndrome (IDS) requiring physician-prescribed bed rest. 9. As service connection is not in effect for right ear hearing loss, the Veteran's hearing acuity in his right ear is regarded as normal (Level I) for VA disability compensation purposes. His service-connected left ear hearing impairment has been manifested by no greater than Level I hearing loss. 10. The Veteran's service-connected postoperative hemorrhoids are not more than moderate in degree; they are not large, thrombotic, or irreducible; involve excessive redundant tissue; or are evidenced by frequent recurrences. 11. The Veteran's service-connected anal fistula is not manifested by impairment of sphincter control with constant slight leakage, or occasional moderate leakage. 12. There is no evidence of penile deformity associated with the Veteran's service-connected erectile dysfunction. 13. The Veteran's service-connected folliculitis, seborrheic dermatitis, and lichen simplex chronicus is currently controlled by topical medication and affects an exposed surface area of no more than 5 percent. It does not more nearly approximate a disability characterized by exfoliation, exudation or itching involving an exposed surface or extensive area and does not require systemic therapy or immunosuppressive drugs. 14. The Veteran's varicose veins in the right foot are manifested by intermittent edema of the extremity with symptoms relieved by elevation. 15. The Veteran's varicose veins in the left foot are manifested by intermittent edema of the extremity with symptoms relieved by elevation. CONCLUSIONS OF LAW 1. A right ear hearing loss disability was not incurred in, or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.385 (2010). 2. A chronic dental disability manifested by tooth pain was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131, 1712, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.381, 4.150, 17.161 (2010). 3. A chronic bilateral foot disability manifested by, claimed as arthritis, was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 4. Chronic residuals of cardiac arrest were not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 5. Chronic residuals of pneumonia, to include a pulmonary granuloma, were not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 6. Chronic adjustment disorder, with depression, is related to military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 7. The criteria for an initial disability rating in excess of 30 percent for nephrolithiasis with recurrent urinary tract infections and voiding problems are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.115b, Diagnostic Code (DC) 7508 (2010). 8. The criteria for an initial disability rating in excess of 10 percent for residuals of a low back injury, status post fusion L4-S1 with degenerative disc disease are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, DC 5241 (2010). 9. The criteria for an initial compensable disability rating for left ear hearing loss are not met. 38 U.S.C.A. §§ 1155, 1160, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.383, 4.31, 4.85, 4.86, DC 6100 (2010). 10. The criteria for an initial compensable disability rating for residuals of internal hemorrhoids, status post multiple bandings are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.114, DC 7336 (2010). 11. The criteria for an initial compensable disability rating for residuals of a perianal abscess and fistula, status post fistulectomy with pruritis ani are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.114, DCs 7332, 7335 (2010). 12. The criteria for an initial compensable disability rating for erectile dysfunction associated with low back injury and hypertension are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.115b DC 7522 (2010). 13. The criteria for an initial 10 percent disability rating, but no higher, for residuals of folliculitis, seborrhic dermatitis, and lichen simplex chronicus of the scalp are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.118, DC 7806 (2010). 14. The criteria for an initial 10 percent disability rating, but no higher, for varicose veins of the right foot are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.104, DC 7120 (2010). 15. The criteria for an initial 10 percent disability rating, but no higher, for varicose veins of the left foot are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.104, DC 7120 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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. 38 C.F.R. § 3.159(b)(1), as amended, 73 Fed. Reg. 23,353 (April 30, 2008). This notice must be provided prior to an initial decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental SOC (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In connection with the Veteran's psychiatric disorder, and as will be discussed in further detail in the following decision, the Board finds that the competent and probative evidence of record supports the grant of service connection for a chronic adjustment disorder with depression. The Board is granting in full this aspect of the Veteran's appeal. Accordingly, without deciding whether any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. As regards the remaining service connection claims for right ear hearing loss, tooth pain, bilateral foot pain, cardiac arrest residuals, and pneumonia residuals (as are adjudicated herein), in a predecisional letter dated in March 2003, the RO informed the Veteran of the information and evidence necessary to substantiate these claims, the division in responsibilities of fulfilling these duties, and the effect of this duty upon his claims. The Board is also aware of the considerations of the United States Court of Appeals for Veteran Claims (Court) in Dingess supra, regarding the need for notification that a disability rating and an effective date for the award of benefits will be assigned if service connection or increased ratings are awarded. However, in this case because the service connection claims in question are being denied, such matters are moot. Moreover, the Veteran has not demonstrated any prejudicial or harmful error in VCAA notice, and any presumption of error as to the first element of VCAA notice has been rebutted in this case. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). With respect to the ratings of the service-connected disabilities currently on appeal, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated; it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Here, the March 2003 letter informed the Veteran of the information and evidence necessary to substantiate his underlying claims for service connection for a kidney disorder, back disorder, left ear hearing loss, hemorrhoids, perianal abscess, erectile dysfunction, skin disorder, and varicose veins. By the April 2004 rating action, the RO granted service connection for these disabilities and assigned various disability ratings. Following receipt of notification of that determination, the Veteran perfected a timely appeal with respect to the ratings assigned. Clearly, based on this evidentiary posture, the Veteran's claims for higher ratings are based on his disagreement with the assignment of specific evaluations following the grant of service connection for these disorders. Dingess, supra; Dunlap v. Nicholson, 21 Vet. App. 112, 116-117 (2007). The Veteran has not demonstrated any error in VCAA notice, and therefore the presumption of prejudicial error as to such notice does not arise in this case. The Board concludes that all required notice has been given to the Veteran. Shinseki v. Sanders, supra. The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claims adjudicated herein. His in-service and pertinent post-service treatment reports are of record, and the RO obtained multiple VA examinations in July 2003, August 2004, June 2006, May 2008, April 2010, and June 2010. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations are more than adequate, as they reflect a full review of all medical evidence of record, are supported by sufficient detail, and refer to specific documents and medical history as well as the Veteran's service history to support the conclusions reached. These VA examinations also provide sufficient detail to rate the Veteran's multiple service-connected disabilities, including a thorough discussion of the effect of his symptoms on his functioning. Thus, the Board finds that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claims under the VCAA. No useful purpose would be served in remanding this matter for yet more development. A remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit to the Veteran. In any event, the Board finds that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); & Quartuccio v. Principi, supra. II. Law and Analysis for Service Connection Claims Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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). Certain chronic diseases are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). A disorder may also be service connected if the evidence of record reveals that the Veteran currently has a disorder that was chronic in service or, if not chronic, that was "noted" in service with post-service continuity of the same symptomatology and medical or lay evidence of a nexus between the present disability and the symptomatology. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). In other words, a Veteran can establish continuity of symptomatology in cases where he/she cannot fully establish the in-service and/or nexus elements of service connection discussed above. See also Hickson v. West, 12 Vet. App. 247, 253 (lay evidence of in-service incurrence is sufficient in some circumstances for purposes of establishing service connection). After considering all information and lay and medical evidence of record in a case 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 benefit of the doubt will be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. A. Right Ear Hearing Loss, Tooth Pain, Bilateral Foot Pain, Residuals of Cardiac Arrest & Residuals of Pneumonia The crux of these particular claims for service connection hinges on the question of whether any current hearing loss, dental, musculoskeletal, cardiovascular, or respiratory disorders are causally related to the Veteran's military service. However, the Board finds that the primary impediment to a grant of service connection is the absence of medical evidence of current disabilities at any time during the current appeal. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the absence of proof of a present disability, there can be no valid claim. Rabideau v. Derwinski, 2 Vet. App. 141, 143- 44 (1992). Analysis of Right Ear Hearing Loss Claim The Veteran contends that he has right ear hearing loss directly related to excessive noise exposure from jet engines as well as repeated ear/sinus infections during service. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies at 500, 1000, 2000, 3000, or 4000 Hz 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. Further, the Court has indicated that the threshold for normal hearing is between 0 and 20 decibels, and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Even if disabling hearing loss is not demonstrated at separation, a veteran may, nevertheless, establish service connection for a current hearing disability by submitting evidence that a current disability is causally related to service. Hensley v. Brown, supra, at 160. Turning to the evidence of record, the Board notes that the RO has already conceded the Veteran's in-service noise exposure in its April 2004 grant of service connection for left ear hearing loss and tinnitus based on such exposure. Service treatment records (STRs) include multiple in-service audiometric examination of the Veteran's hearing acuity none of which reflect right ear hearing thresholds that meet the criteria for disability under VA regulations-or, indeed, any degree of right ear hearing loss. Furthermore, according to post-service treatment records, in July 2003, the Veteran was referred for examination for the specific purpose of obtaining an opinion as to whether or not any current right ear hearing loss could be related to service. His chief complaint was difficulty hearing in all situations. Pure tone thresholds for the Veteran's right ear were 5, 5, 10, 15, and 25 decibels at 500, 1000, 2000, 3,000, and 4000 Hz, respectively. Speech audiometry revealed speech recognition ability of 96 percent. The audiologic test results indicate essentially normal hearing in the right ear. Also of record is private audiogram report dated in April 2005, which shows pure tone thresholds for the Veteran's right ear were 15, 15, 15, 20, and 30 decibels at 500, 1000, 2000, 3,000, and 4000 Hz, respectively. Speech audiometry revealed speech recognition ability of 96 percent. The Board notes that although the private audiologist provided numerical values for the pure tone results at frequencies 500, 1000, 2000, 3000, and 4000 Hertz, the report does not otherwise conform to VA's requirements for evaluating hearing impairment, in that it is not clear that the examiner derived speech discrimination results using the Maryland CNC speech discrimination test. See 38 C.F.R. § 4.85(a). The remaining evidence of record is negative for documentation of right ear hearing loss for VA purposes. In this case, the post-service evidence clearly does not show right ear hearing loss as defined by VA regulations at any time during the current appeal. The measurements of the Veteran's right ear hearing acuity do not satisfy any of the three alternate bases for establishing hearing loss disability under 38 C.F.R. § 3.385. In particular, the findings do not show a puretone threshold in any critical frequency was 40 decibels or greater, that three or more frequencies were 26 decibels or greater, or that the speech recognition score was less than 94 percent. Therefore the Veteran does not have right ear hearing loss for which service connection could be awarded for VA purposes, notwithstanding that he may have had noticeable loss of hearing acuity. See Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001); Sanchez-Benitez v. West, 13 Vet. App. 282 (1999) (service connection may not be granted for symptoms unaccompanied by a diagnosed disability). Further, the claims folder contains no competent evidence refuting these audiological findings. Analysis of Tooth Pain Claim The Veteran contends that the teeth on the right upper side have been painful and extremely sensitive to cold/heat as a result of sinus surgery performed during military service. Disability compensation and VA outpatient dental treatment may be provided for certain specified types of service-connected dental disorders. For other types of service-connected dental disorders, the claimant may receive treatment only and not compensation. 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 4.150, 17.161. Dental disabilities that may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, DCs 9900-9916. Under 38 C.F.R. § 3.381, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal diseases are to be considered service-connected only for the purpose of establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161. Here, STRs also show the Veteran was treated for recurrent sinus infections including several surgeries to remove nasal polyps and correct a deviated septum. These records also show that the Veteran was treated for recurrent episodes of sinusitis, pharyngitis, and various other upper respiratory infections. Associated symptomatology included ear pain, sore throat, nasal drainage, sinus congestion, right cheek pain, eye pain, and teeth pain. Service dental records reveal routine dental restorations and cleanings and reference to inadequate oral hygiene and periodontal surgery. There is no documentation of oral or maxillofacial trauma. Specifically, in January 2000, the Veteran was evaluated for a fistula on the left palate in the area between the 2nd and 3rd molars, which was subsequently attributed to a recurrent sinusitis. In January 2001, he presented with a three day history of right cheek and tooth pain. It was noted that he was recovering from an upper respiratory infection. In July 2002, the Veteran was evaluated for complaints that the teeth on the top right side were painful. His history of chronic sinusitis was noted. Examination revealed the right maxillary sinus was tender to percussion. An intraoral examination revealed that teeth numbers 1-4 were all tender to percussion, but the 2nd and 3rd had a fracture of the distal marginal ridge. The Veteran's periodontal health was otherwise within normal limits. X-rays revealed a mucocele in the right maxillary sinus. The clinical impression was possible right maxillary sinusitis with presence of mucocele and fracture of the distal marginal ridge of teeth numbers 2-3, which required replacement. In October 2002, the Veteran was evaluated for possible sinus infection. It was later determined that he had tooth decay and he underwent nerve root canal of tooth number 12 in November 2002. At his retirement examination in January 2003, the Veteran reported a history of tooth pain since 1989. These records do not attribute any missing teeth or any other dental condition to service trauma. During VA general medical examination in July 2003, dental findings were normal. The Veteran underwent a second VA general medical examination in April 2010. At that time examination of the mouth and throat showed that the Veteran's teeth were in good repair and that his gums were normal. The post service evidence is otherwise devoid of any post-service dental records or documentation of a current dental condition. The Board notes that service connection was subsequently established for sinusitis in April 2004 and rated as 10 percent disabling. Based upon the foregoing, the Board concludes that there is no basis under the law for the award of service-connected VA disability compensation for the Veteran's current dental condition. He is not eligible for VA compensation as his current dental condition does not fall under the categories of compensable dental conditions set forth in 38 C.F.R. § 4.150 (outlined above). The Board does not dispute that the Veteran may have a history of teeth pain, but there is no objective clinical confirmation that he suffers from an actual dental disorder at any time during the current appeal. See Sanchez-Benitez, supra. A review of the complete medical record, which includes both in-service and post-service medical evidence is negative for findings of trauma prior to or resulting in the removal of any teeth. STRs are entirely negative for evidence of any injury or residual impact involving the mouth, jaw, tongue or other bone or muscles of the mouth. The post-service medical records contain no current diagnosis of a dental disability related to an in-service injury, nor is there any competent opinion to indicate that the Veteran had continuing symptomatology as a result of any injury during service. In fact, the Veteran has not submitted any medical evidence identifying the specific teeth for which he is seeking service connection, nor has he put VA on notice that any such evidence is available and could be obtained. Although the Veteran's tooth pain has been specifically claimed by him as a separate disability, clinical findings, as well as his own complaints, consistently reflect that any history of tooth pain represents a manifestation and/or symptom of his currently service-connected sinusitis, as opposed to an independent and separate and distinct disability, or a symptom of a different condition. Under VA law and regulations, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14; see also Fanning v. Brown, 4 Vet. App. 225 (1993). The critical inquiry in making such a determination is whether any of the symptomatology is duplicative or overlapping; the veteran is entitled to a combined rating where the symptomatology is distinct and separate. See Esteban v. Brown, 6 Vet. App. 259 (1994). In other words, to the extent the Veteran has teeth pain, it is part and parcel of his service-connected sinusitis, a condition for which he is already being compensated. Therefore this service connection claim is denied. Analysis of Bilateral Foot Pain Claim The Veteran asserts that he has arthritis in both feet as a result of marching and physical training during military service. STRs fail to reveal any significant foot complaints other than in March 2002 when the Veteran was treated for complaints of a right foot pain and numbness of the right leg. It appears that the episode was acute in nature and had resolved with treatment and without extended follow-up. Other entries note treatment for right ankle pain, but do not address any bilateral foot complaints as none were made. At his retirement examination in January 2003, the Veteran reported problems with his feet as a result of over-use type injuries. There were no other findings to suggest a chronic bilateral foot disorder or that provide a basis for such a diagnosis. When examined by VA in July 2003, the Veteran complained of dull ache in both feet after prolonged standing or when he running. He denied any specific surgery or injury and there was no specific treatment other than nonsteriodals anti-inflammatories, corrective shoes, and orthotics. The Veteran was able to participate in normal activities. Examination of the feet showed no evidence of painful motion, edema, instability, weakness or tenderness. His gait and posture were normal and there was no abnormal shoe wear pattern. There was also no evidence of hammer toes, high arches, claw foot, hallux valgus, or other deformity. Although the Veteran did have rather low arches, he did not have flat feet. He was able to flex each foot to 85 degrees and extend to 25 degrees. He was also able to move medially, and laterally about 35 degrees. Pain did not limit the motion of the ankle or foot. X-rays of both feet were within normal limits. A subsequent VA examination in April 2010, revealed no abnormal findings or deformities of either foot including flat feet. There was 1-centimeter scar over the right medial dorsal foot area from a prior excision of a cactus spine. The remaining evidence of record is negative for documentation of degenerative changes in either foot. In this case, the medical evidence indicates that the Veteran does not currently have a chronic bilateral foot disability. While foot pain is the type of symptom capable of lay observation, the record is devoid of objective clinical confirmation that he suffers from an actual disability. Treatment records, show few, if any, references to bilateral foot pain, with no objective clinical evidence of a disability to account for the symptoms. In addition the VA examiners did not indicate any identifiable pathology involving either foot despite his complaints. In the absence of a clear diagnosis of a bilateral foot disability, or abnormality which is attributable to some identifiable disease or injury during service, at any time during the current appeal, an award of service connection is not warranted. See Sanchez-Benitez supra. Analysis of Cardiac Arrest Claim The Veteran contends that he suffered a cardiac arrest during an in-service back surgery and has had continuing residuals of shortness of breath and fatigue. STRs show the Veteran was hospitalized for about one week after developing complications with general anesthesia and suffering a cardiac arrest during an attempted spinal fusion. A post operative radiology report showed no acute chest abnormality and a ventilation/perfusion lung scan was normal. An echocardiography report showed the ventricles were normal, in size, shape, and systolic performance. The atrial chamber dimensions were also normal. The valves were normal in structure and function. A cardiac ultrasound showed the heart was borderline in size with no overt evidence of failure. There was no pleural fluid or acute appearing infiltrate seen. The Veteran successfully underwent spinal fusion in August 2000 without evidence of permanent residuals or chronic injury as a result of the cardiac arrest. Likewise, the post-service medical records show no current diagnosis of a heart disorder, nor is there any competent opinion to indicate that the Veteran had permanent residuals as a result of the cardiac arrest during service. When examined by VA in July 2003, the Veteran's heart had a regular rate and rhythm without evidence of murmur. There were no abnormal heart sounds and no indication of angina, arrhythmia, or coronary artery disease. X-ray revealed the cardiac size and pulmonary vasculature were within normal limits. The bony thoracic cage was grossly intact. The examiner did not indicate any identifiable pathology involving the heart. During VA examination in April 2010, there was no history of rheumatic fever, hypertensive heart disease, heart rhythm disturbance, valvular heart disease, congestive heart failure, other heart disease or angina. However, the Veteran's history was significant for hypertension and a myocardial infarction in 2000. His primary complaint was dyspnea on mild exertion. Cardiac examination findings revealed no evidence of congestive heart failure or pulmonary hypertension. Heart rhythm was regular and sounds were S1, S2 with no extra heart sounds. Peripheral pulses were 2+ and there was no peripheral edema noted. A chest X-ray showed no evidence of significant cardiovascular pathology other than mild cardiomegaly which the examiner associated with the Veteran's service-connected hypertension. (See April 2010 VA examination report p.60). The post service evidence is devoid of any indication that the Veteran is currently being treated for residuals of cardiac arrest. Although the Veteran was hospitalized for cardiac arrest during service, he has not been diagnosed as having any chronic disabling residuals as a result. See Clyburn v. West, 12 Vet.App. 296, 301 (1999). That a condition or injury occurred in service alone is not enough; there must be a current disability resulting from that condition or injury. See Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Chelte v. Brown, 10 Vet. App. 268, 271 (1997). While the Board does not dispute that the Veteran may experience relevant symptoms, there is no objective clinical confirmation that he suffers from an actual disability at any time during the current appeal. See Sanchez-Benitez supra. The Veteran has not been shown to have any identifiable pathology of the heart at any time during active military service. There is no post-service evidence that the Veteran is currently being treated for residuals of the cardiac arrest, and neither VA examiner found objective clinical evidence of any residuals. Instead, it appears that the cardiac arrest diagnosed in service was drug-induced (anesthesia) and of an acute nature without permanent residuals or continuity thereof. Moreover, the Veteran was provided VA examinations in 2003 and 2010, and neither examiner found objective clinical evidence of organic heart disease to account for the symptoms. Although cardiomegaly may, or may not, be a manifestation of a chronic disorder, it is not by itself disabling and in any event was determined to be related to hypertension. In the absence of a clear diagnosis of a residuals of cardiac arrest, or some other abnormality which is attributable to some identifiable disease or injury during service, at any time during the current appeal period, an award of service connection is not warranted. Analysis of Pneumonia Claim The Veteran contends that he was treated for pneumonia in service and developed permanent residuals claimed as scarring of both lungs. STRs show the Veteran was treated on numerous occasions for respiratory complaints, with assessments including chronic sinusitis, pharynigitis, upper respiratory infections, tonsillitis, bronchitis and pneumonia. Following his first episode of pneumonia in November 1992, X-ray findings revealed a mild deformity of the lateral aspect of the right clavicle, probably due to old trauma with no other findings noted. A subsequent X-ray in February 1993 showed a 1.5 centimeter radiopacity over the area of the right 6th rib which was later confirmed to be a pulmonary granuloma. Over a two year period, the Veteran underwent chest X-rays every six months. These X-rays showed no change in the stable right lower lobe pulmonary nodule. At his retirement examination in January 2003, the Veteran noted problems with breathing, which he attributed to enlarged tonsils and a deviated septum. During VA examination in July 2003, the Veteran gave a history of recurrent pneumonia during service with residual scarring of the lungs. He had no history of surgery and was not currently being treated for this. There was no evidence of malignant disease present. On examination the lungs were clear to auscultation bilaterally with good air exchange. There was no evidence of pulmonary hypertension, right ventricular hypertrophy, respiratory failure, or chronic pulmonary thromboembolism. A chest X-ray showed what the examiner believed to be a nipple shadow in the right lower lung region. A repeat study with nipple marker was recommended. During reexamination in August 2004 the examiner noted the Veteran's history of in-service pneumonia as well as his history of sleep apnea. A repeat X-ray confirmed old granulomatous disease in the right lower lung, but otherwise showed no acute disease. Pulmonary function tests revealed a mild restrictive ventilatory defect, which was described as normal. The pulmonary diagnosis was sleep apnea. During VA examination in April 2010, the Veteran's pulmonary history was negative for, among other symptoms, coughing, wheezing, hemoptysis, night sweats, respiratory failure, cor pulmonale, pulmonary hypertension, chronic pulmonary mycosis, spontaneous pneumothorax, asthma, pulmonary embolism or pleurisy. His primary complaints were of dyspnea on mild exertion, non-anginal chest pain, sleep apnea, and bronchiectasis. Examination findings showed no evidence of abnormal breath sounds. Respirations were even and non-labored without shortness of breath. A chest X-ray showed a few healed granulomas. The examiner did not otherwise indicate any identifiable pathology involving the lungs. The post service evidence is devoid of any indication that the Veteran is currently being treated for residuals of pneumonia. Although the Veteran was treated for recurrent episodes of pneumonia in service, there is no clinical confirmation that this caused any chronic impairment or permanent residuals. Moreover, he was provided VA examinations in 2003 and 2010 and neither examiner found objective clinical evidence of respiratory residuals that could be attributed to the pneumonia. The Veteran has presented no competent medical evidence to the contrary. Although a pulmonary granuloma may, or may not, be a manifestation of a chronic disorder, it does not appear to be by itself disabling. Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1. See Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). Nothing in the medical evidence reflects that the Veteran has exhibited a disability manifested by the pulmonary granuloma at any time during the current appeal period, and there is no evidence of record to suggest that it causes any impairment of earning capacity. There are no symptoms, manifestations, or any deficits in bodily functioning associated with this finding. A clinical finding, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez supra. In the absence of a clear diagnosis of a lung disorder, or abnormality which is attributable to some identifiable disease or injury during service, an award of service connection is not warranted. B. Conclusion The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). Importantly, however, and of particular significance to the Board in this matter, is the fact that, at no time during the current appeal have diagnoses of right ear hearing loss or chronic disabilities manifested by tooth pain, bilateral foot pain, residuals of cardiac arrest, or residuals of pneumonia been made. Based on this evidentiary posture, service connection cannot be awarded. Finally, in reaching the above conclusions, the Board has not overlooked the Veteran's contentions, his complaints to healthcare providers, his written statements, or his hearing testimony. As to his assertions that he developed the claimed disabilities as a result of service, the Board acknowledges that he is competent to give evidence about what he sees and feels; for example, he is competent to describe decreased hearing, acute illness/injuries, pain, fatigue, or shortness of breath. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board is also aware that lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994) Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). 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. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). That said, the Board notes that the Veteran is not a medical professional, and therefore, his beliefs and statements about medical matters do not constitute competent evidence on matters of medical etiology or diagnosis. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). In this case, his contentions are not statements merely about symptomatology, an observable medical condition, or a contemporaneous medical diagnosis, but rather clearly fall within the realm of requiring medical expertise, which he simply does not have. The VA examination reports currently contained within the claims file do not establish diagnoses of right ear hearing loss or chronic disabilities manifested by tooth pain, bilateral foot pain, cardiac arrest residuals, or pneumonia residuals at any time during the current appeal. Therefore, the Veteran's opinion, to the extent it is to be accorded some probative value, is far outweighed by these factors. See Jandreau supra & Buchanan supra. Accordingly, for these reasons, the preponderance of the evidence is against these claims. There is no reasonable doubt to be resolved. 38 U.S.C.A. § 5107(b). C. Analysis of Acquired Psychiatric Disorder Claim STRs include an entry date in December 1998 which shows the Veteran was evaluated for stress secondary to high stress job but denied depression. In a January 1999 health assessment questionnaire he again reported considerable stress at work and home as well as depression and anxiety symptoms. When examined by VA in July 2003, the Veteran indicated that he had never seen a psychiatrist except on one occasion in 1993 when he was assigned to do an investigation which essentially concluded that Air Force doctors were overbilling the VA. He stated that as a result of the report he was fired from his assignment and placed under the supervision of his captain. The Veteran stated that after this incident he began to feel persecuted and his decorations disappeared. He was later referred to military psychiatrist or psychologist for being "histrionic." Currently, the Veteran denies being depressed, but stated that he was "pissed off" thinking about what happened to him in the Air Force and reported that he had a lawsuit pending against them. The Veteran complained that he did not sleep well secondary to back pain and constantly worries about his lawsuit. He denied any nightmares or flashbacks. The clinical impression was adjustment disorder. Unfortunately the examiner did not offer an opinion concerning the etiology of the Veteran's adjustment disorder, and, in particular, whether it had its onset in service. Post service medical records also include an April 2004 outpatient treatment record, which shows the Veteran reported symptoms of anxiety and depression, but declined any medical therapy at that time. A mental health consultation report in February 2007 shows a continued diagnosis of chronic adjustment disorder with mixed emotions and flashbacks. The Board finds that the evidence demonstrates continuity of symptomatology, linking the adjustment disorder to service. The Veteran filed his claim in March 2003, approximately one month after his separation from service, contending that his current depression was related to his period of active service. Here, the Board finds that, because the Veteran applied for compensation benefits for an acquired psychiatric disorder, shortly after service, his current assertions of having depression since service are found to be credible. Moreover, he is found to be competent to report his symptoms of depression. Post-service records document a history of fairly continuous mental health issues since service. Despite the lack of a clear nexus opinion, the weight of credible medical evidence shows that the Veteran has been diagnosed with adjustment disorder related, at least in part, to events in service as reported to VA examiners and adjudicators. The Board finds that the evidence concerning whether a chronic psychiatric disorder began in service is at least in relative equipoise. Given the aforementioned, the Board finds that the criteria for service connection for a chronic adjustment disorder with depression have been met. Accordingly, and resolving all doubt in the Veteran's favor, the Board finds that service connection is warranted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.303(b). In reaching this decision, the Board acknowledges that a December 2010 VA outpatient treatment record contains a diagnosis of PTSD related to the Veteran's whistle blowing incident where he was assigned to investigate billing misconduct by Air Force medical officers. However, this diagnosis was not made based on a verified in-service stressor. See 38 C.F.R. § 3.304(f). Accordingly, the Board finds that the psychiatric disorder for which service connection is being granted by this decision is best characterized as a chronic adjustment disorder with depression. III. Law and Analysis for Increased Ratings Disability evaluations are determined by comparing a veteran's present symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2010). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See also Fenderson v. West, 12 Vet. App. 119 (1999). In this case, the Veteran contends that his service-connected disabilities are more disabling that their current disability ratings reflect. A. Analysis of Kidney Disorder Claim In an April 2004 rating action, service connection was granted for nephrolithiasis claimed as kidney stones with recurrent urinary tract infections and voiding problems and a 30 percent evaluation was assigned under DC 7508. The Veteran appealed the initial evaluation assigned. Diseases of the genitourinary system generally result in disabilities related to renal or voiding dysfunctions, infections, or a combination of these. The rating schedule provides descriptions of various levels of disability in each of these symptom areas. Where diagnostic codes refer the decisionmaker to these specific areas of dysfunction, only the predominant area of dysfunction shall be considered for rating purposes. Since the areas of dysfunction do not cover all symptoms resulting from genitourinary diseases, specific diagnoses may include a description of symptoms assigned to that diagnosis. See 38 C.F.R. § 4.115a. The Veteran's recurrent kidney stones are currently rated as 30 percent under DC 7508 for nephrolithiasis. Under that diagnostic code a maximum 30 percent rating is assigned for recurrent stone formation requiring one or more of the following: diet therapy, drug therapy, and/or invasive or non-invasive procedures more than two times a year. 38 C.F.R. § 4.115b. A maximum 30 percent rating is also assigned for frequent attacks of colic with infection (pyonephrosis) and impaired kidney function. See 38 C.F.R. § 4.115b, DC 7509. Similarly, the criteria under DCs 7510 (ureterolithiasis), and 7511 (stricture of ureter) only provide for a maximum 30 percent rating as well. In an effort to afford the Veteran the highest possible evaluation, the Board has considered whether the kidney disorder warrants evaluation as renal dysfunction or voiding dysfunction. In this context, renal dysfunction is rated at 30 percent when there is constant or recurring albumin with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101. A 60 percent rating is warranted when there is constant albuminuria with some edema; or definite decrease in kidney function; or hypertension at least 40 percent disabling under diagnostic code 7101. An 80 percent rating requires persistent edema and albuminuria with BUN 40 to 80 mg%; or creatinine 4 to 8mg%; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating requires regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or BUN more than 80mg%; or creatinine more than 8mg%; or markedly decreased function of kidney or other organ systems, especially cardiovascular. See 38 C.F.R. § 4.115a. Under DC 7101 a 40 percent rating is provided for hypertension manifested by diastolic pressure predominantly 120 or more with moderately severe symptoms. 38 C.F.R. § 4.104. Voiding dysfunctions are addressed under 38 C.F.R. § 4.115a, which directs that the particular condition be rated as urine leakage, urinary frequency, obstructed voiding, and urinary tract infection. Urinary leakage involves ratings ranging from 20 to 60 percent and contemplates continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence. When there is leakage requiring the wearing of absorbent materials, which must be changed 2 to 4 times per day, a 40 percent disability rating is warranted. When these factors require the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day, a 60 percent evaluation is warranted. See 38 C.F.R. § 4.115a. Urinary frequency encompasses ratings ranging from 10 to 40 percent. A 40 percent rating contemplates a daytime voiding interval less than 1 hour, or awakening to void 5 or more times per night. Id. Obstructed voiding and urinary tract infection both provide maximum 30 percent ratings for urinary retention requiring intermittent or continuous catheterization, as well as recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. Id. Therefore, no greater benefit can flow to the Veteran under these diagnostic codes. Turning to the evidence of record, at a his post-service VA examination in July 2003, the Veteran complained of some tiredness, but no anorexia, weight loss, or weight gain associated with the stones. He had daily urination that was somewhat painful at times and he had difficulty initiating a urine stream. He noted mild incontinence of small amounts of leak with his urine. He also gave a history of urinary tract infections since the 1980s and had recently had a stent placed in his urinary tract. The Veteran had associated kidney stones, but no acute nephritis, or hospitalizations for urinary tract disease in the past year. There was no history of treatment for malignancy and no catheterization, dilations, drainage procedures, diet therapy or medications were needed. On examination his blood pressure was 136/96. The examiner reviewed radiological findings including a CT scan of the abdomen and a retrograde pyelogram which showed evidence of kidney stones just before the stent was placed in his urinary tract. The clinical impression was kidney stones as confirmed by CT and pyelogram. The examiner opined that placement of the surgical device in the Veteran's urinary tract, would set him up for recurrent urinary tract infections in the future. The condition did not affect the Veteran's employability, but did affect his daily activities as he would have to deal with the urinary tract and kidney stones indefinitely. During VA examination in August 2004, the examiner noted that the stent had been removed in August 2003. Prior to that the Veteran had been hospitalized for renal calculi in July 2003 for a lithotripsy and basket retrieval of stones. His last episode of renal calculi was in July 2004, and that stone passed on its own. An IVP (intravenous pyelogram) with nephrogram in June 2004 showed a single right renal calculi in the mid-pole and multiple left renal calculi in the lower pole. The kidneys were normal. A CT scan at that time showed bilateral nephrolithiasis, but no hydronephrosis or ureter obstruction. The Veteran denied any weakness, loss of appetite, or lethargy. He voided three to four times per day with no nocturia. He denied incontinency but on rare occasions had an episode of leaking with coughing or sneezing, i.e. stress incontinence with an approximately quarter-sized area of drainage, which did not require the use of pads. The Veteran had a history of urinary tract infections in the past with the most recent in 2000, which was treated with antibiotics. He had no history of malignancy of the urinary tract, bladder, or prostate and did not require catheterization, dilatation, or drainage procedures. His diet was regular although he tried to avoid caffeine and foods containing high iron. He was not on any medication for his renal calculi. Most studies indicated that both kidneys were functioning normally and there was no evidence of hydronephrosis or ureter obstruction. His urinalysis was negative. The clinical impression was recurrent and multiple renal calculi. In November 2004 the Veteran was evaluated for complaints of left flank pain. A CT scan of the pelvis showed no hydroureter or renal stones in the pelvis. A CT scan of the abdomen showed small nonobstructing stone in the upper pole collecting system of the right kidney without evidence of hydronephrosis. During VA examination in June 2006, the Veteran reported a history of multiple lithotripsies to break up recurrent kidney stones. Currently he was being treated with pain medication and trying to let any existing stones pass as they occur. He reported nocturia at least once a night. He did not have incontinence and the urinary stream was fairly good. He has had several recurrent urinary tract infections treated with antibiotics. He had not had any malignancies, catheterizations, or invasive procedures. A urinalysis from April 2006 was completely negative and laboratory results showed essentially normal renal function. The clinical impression was bilateral calculi with multiple episodes of urethral stones, stent placements, and lithotripsies. The most recent VA examination, conducted in April 2010, shows the Veteran's history and complaints of recurrent kidney stones was essentially unchanged. He noted some urinary frequency, but denied any problems with abnormal flow, urgency, dysuria, hesitancy, flank pain, or hematuria. He reported daytime voiding intervals of 2-3 hours and voiding once at night. He denied a history of incontinence, obstructive voiding, or urinary tract infection. The laboratory results showed normal renal function with a creatinine level of 1.4 mg/dl (reference range .8-1.5). There was trace amount of protein in the urine and slightly elevated blood urea nitrogen (BUN) of 22 mg/dl (reference range of 9-21). Blood pressure readings taken during this time period were 144/114, 160/108, and 164/110. The clinical impression was history of kidney stones, which would have no effect on the Veteran's usual occupation or daily activities unless he was actively passing a stone. Based on the preceding evidence, the criteria for a rating in excess of 30 percent for the Veteran's kidney disorder have not been met. The medical evidence associated with the claims file does not reveal that he has constant albuminuria, edema, or definite decrease in kidney function. With the exception of recurrent kidney stones, he has remained stable with no significant change in his renal function. The Veteran is noted to be separately evaluated for hypertension at 10 percent disabling, which is not on appeal in this instance. However, as discussed earlier, the medical evidence upon which the separate 10 percent rating for hypertension is based fails to record a single reading demonstrating a diastolic pressure of 120 or more, which would suggest the presence of severe kidney pathology which would warrant a 40 percent rating. See 38 C.F.R. § 4.104, DC 7101. Therefore, the Veteran fails to meet any of the criteria for the next higher evaluation of 60 percent under the schedular criteria for renal dysfunction. Although the Veteran complains of a urinary leakage, this appears to be episodic in nature and was described as minimal. There is also no evidence that any leakage requires the wearing of absorbent materials that must be changed 2-4 times per day as is necessary for a 40 percent evaluation. In addition, the Veteran's reports of daytime frequency of every 2-3 hours, does not amount to daytime voiding intervals less than one hour. There is also no indication of nocturia of five or more times. The Board finds that such symptomatology does not warrant a rating in excess of 30 percent under the rating criteria pertinent to voiding dysfunction or urinary frequency. The remaining rating criteria for evaluating genitourinary disorders either are not applicable to the Veteran's case or do not offer a higher disability rating. 38 C.F.R. § 4.115b, DCs 7500-7507 and DCs 7512-7528. B. Analysis of Lumbar Spine Claim In an April 2004 rating action, service connection was granted for status post spinal fusion of L4-S1 with degenerative disc disease and a 10 percent evaluation was assigned under DC 5241 for spinal fusion. The Veteran appealed the initial evaluation assigned. The Board notes that the RO also assigned a separate 10 percent rating under DC 8726 for radiculopathy of the right leg as related to the service-connected lumbar spine disability. In January 2006, the RO assigned a separate 10 percent rating under DC 8720 for left lower extremity radiculopathy as related to the service-connected lumbar spine disability. The criteria for rating disabilities of the spine are listed under DCs 5235 to 5243. Under DC 5241, a 10 percent evaluation is appropriate where there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is appropriate where there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation for forward flexion of the thoracolumbar spine of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71. Normal forward flexion of the thoracolumbar segment of the spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. See Note 2, General Rating Formula for Disease and Injuries of the Spine, 38 C.F.R. § 4.71a, Plate V. When examined by VA in July 2003, the Veteran reported a history of laminectomy and bone fusion in 2000 for lumbar disc disease with right lower extremity radiculopathy. His current complaints were of constant pain, described as 3/10 at its baseline that occasionally increases to 4-5/10. There were no specific flare-ups. His treatment included cortisone injections, and oral medication. The surgery helped tremendously with the back pain, but he now has numbness and pain in both legs. He had no bowel complaints, erectile dysfunction, visual disturbances, dizziness, or malaise. He occasionally uses a back brace, but could walk about one mile without any problem. He also reported occasional falls when his legs become extremely weak. He had no problems with activities of daily living and it did not affect his usual occupation or recreational activities. On examination the limbs, posture and gait were all normal. Range of motion testing revealed flexion to 70 degrees, extension to 15 degrees, and lateral flexion to 15 degrees, bilaterally with pain limiting all ranges of motion. There was some objective evidence of spasm. Sensory examination was 4/5 at the right sacral area, but 5/5 on the left sacral area and in both lower extremities. Reflexes were 2+ in the lower extremities and strength was 5/5. There was no evidence of intervertebral disc syndrome. X-rays of the lumbar spine showed minor anterior spurring at L3, L4, and L5 with minor L5-S1 joint space narrowing. The clinical impression was low back pain secondary to degenerative joint disease and bulging nucleus pulposus (herniated disc). The examiner noted the Veteran was fully employable. During VA examination in August 2004, the Veteran continued to complain of radiating back pain at the base of the spine with prolonged sitting. On examination the midline lumbar spine was nontender to palpation without palpable deformity. He was tender over the right sacroiliac. There were no spasms or warmth and straight leg raising was negative. Forward flexion was to 90 degrees, with pain from 30 degrees on. Extension was -20 degrees, with pain from -10 degrees, bilateral bending was full at 30 degrees with pain on the left. Right rotation was to 20 degrees with pain and left lateral rotation was full at 30 degrees with pain. Gait was normal and motor strength was 5/5 bilateral lower extremities. Sensation was intact in both lower extremities to monofilament testing and symmetrical along the thighs and lateral calves. Deep tendon reflexes were 2+ at the patellae and Babinski's were toes down normally. X-rays of the lumbar spine showed mild disc space narrowing at L5-S1 and anterior osteophyte formation at several levels. The clinical impression was lumbar disease status post laminectomy and internal fixation and bone graft with radiculopathy to both lower extremities. The Veteran was able to perform activities of daily living and was able to work as long as he modified his movements. There were no reports of bowel or bladder problems. In a September 2004 addendum to this opinion, the examiner noted the Veteran had minimal low back pain since the surgical repair in 2000. The pain occurs with exertion or heavy lifting and therefore can occur daily unless the Veteran modifies his activities. The pain radiates to the right thigh and calf laterally, but is primarily a numb sensation. The Veteran indicated that the pain had nearly resolved. He has had no flare-ups or incapacitation since the surgery. He does not require a cane or brace. Currently he is able to perform activities of daily living and work full-time. With repetitive motion testing were was no change in symptoms. During VA examination in May 2008, the Veteran's complaints of radiating back pain remained the same except now he reported flare-ups 2-3 times a month. The pain was precipitated by bending, lifting, and relieved with rest and medication. There were no episodes of incapacitation, but he noted that the back pain had slowed him down considerably. On examination lumbar lordosis was lost, the spine was straight and there was tenderness to percussion. Straight leg raising was to 45 degrees with pain at 30 degrees, bilaterally. Range of motion showed lumbar flexion to 30 degrees, extension to 0 degrees, lateral flexion to 20 degrees, bilaterally, and rotation to 30 degrees bilaterally. There was pain with range of motion. Repetitions of three produced increased pain, weakness, lack of endurance, fatigue, and incoordination. Lasegue testing was positive bilaterally. Deep ankle and knee reflexes were present and plantars were downgoing bilaterally. Cremasteric reflexes and rectal tone were normal. The Veteran complained of altered sensations in the dermatome extending from L3 to S1, bilaterally. There was no motor or autonomic dysfunction. Muscle power was grade 5. Radiological findings were consistent with status post decompressive laminectomy and lumbar fusion at L5-S1 with no acute abnormality. Also of record is a medical opinion from a private physician noting treatment of the Veteran since 2006. He stated that despite therapy, medication, and injections, over a given 12-month period the Veteran had at least 4-6 weeks of incapacitating episodes. During VA examination in April 2010, the Veteran's complaints of low back pain with radicular symptoms were essentially unchanged. Examination revealed tenderness in the lumbar spine and paramusculature areas with associated spasm. There was no guarding, atrophy or weakness of the muscles. There was no spinal ankylosis. Lower extremity motor testing was 5/5 strength for all muscle groups. There was scattered loss of sensation to bilateral legs following no specific dermatomal distribution. Reflexes were 2+ in the legs. Straight leg testing was negative. Forward flexion was to 75 degrees, extension to 25 degrees, lateral flexion to 25 degrees, bilaterally, and rotation was 20 degrees, bilaterally. The Veteran complained o f pain during end stage range of motion. CT scan of the lumbar spine showed L5-S1 anteriolisthesis with previous pedicle screw placement at L5-S1 decompressive laminectomy. There were no other disc space abnormalities. The clinical impression was history of lumbar fusion without evidence of radiculopathy, which causes decreased mobility and problems with lifting and carrying. The examiner noted the Veteran would need to avoid repetitive bending, stooping, squatting or twisting lifting or carrying more than 15-20 pounds. The most recent treatment record is a June 2010 VA examination report, which contains clinical findings similar to those from the April 2010 VA examination. Posture and gait were both normal and with the exception of lumbar flattening there were no abnormal curvatures of the spine. There was evidence of spasm and tenderness of the thoracic sacrospinalis. It was noted that part of the thoracolumbar spine was ankylosed due to the L5-S1 fusion. However range of motion testing showed forward flexion was to 75 degrees, extension to 20 degrees, lateral flexion to 20 degrees, bilaterally, and rotation to 20 degrees, bilaterally. The Veteran reported pain with motion with flexion from 50 to 75 degrees and end stage extension and lateral flexion and rotation. Motor examination showed 5/5 with no motor impairment. Motor tone and reflex examinations were both normal and there was no evidence of atrophy. Sensory examination revealed decreased sensation in the entire thigh and great toe bilaterally. X-rays of the lumbar spine showed progressive degenerative changes and satisfactory appearing L5-S1 fusion. Applying the regulations to the facts in the case, the Board finds that the criteria for a rating in excess of 10 percent for the Veteran's lumbar spine disability are not met. During the course the appeal, the Veteran's complaints (primarily, pain, weakness, and instability) appear to have remained essentially unchanged, and are clearly referenced in the examination reports. However, objective medical evidence is the most persuasive indication of functional loss resulting from the Veteran's lumbar spine disability. With one exception, the record largely reflects findings of essentially normal or near-normal range of motion. There is no indication that the lumbar spine disability results in muscle spasm, an abnormal gait, or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Thus, the Board finds that the criteria for an evaluation greater than 10 percent have not been met. In this case, there is no credible evidence of pain on use or flare-ups that result in limitation of motion to the extent that the lumbar spine would warrant a higher rating. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). It is not disputed that the Veteran has limitation of motion of the thoracolumbar segment of the spine and that there is significant pain on motion. Yet, the Board finds that the 10 percent disability rating adequately compensates him for his painful motion and functional loss. Given that the Veteran's complaints do not prevent him from achieving a substantial measured range of motion they do not support a finding of additional functional loss for a higher rating. Although the Board is required to consider the effect of the Veteran's pain when making a rating determination, and has done so in this case, the Rating Schedule does not provide for a separate rating for pain. Rather, it provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. Spurgeon v. Brown, 10 Vet. App. 194 (1997). In this case, the Veteran is already being adequately compensated for pain. The Board has also considered whether an increased evaluation is in order in this case when separately evaluating and combining the orthopedic and neurologic manifestations of the Veteran's lumbar spine disability. In this case, there is no current clinical or diagnostic evidence of additional, separate neurologic impairment. Although the Veteran has some radiculopathy, he is currently service-connected for radiculopathy of the right and left lower extremities, which the RO has rated separately under DC 8726 and DC 8720, respectively. 38 C.F.R. § 4.124a. These diagnostic codes pertain to disabilities involving the femoral and sciatic nerves and separate 10 percent disability ratings were assigned effective from March 1, 2003. Thus, consideration of separately evaluating and combining the neurologic and orthopedic manifestations of the Veteran's lumbar spine disability would not result in a higher rating. See 38 C.F.R. § 4.14. With respect to a higher rating based on the frequency and extent of incapacitating episodes (defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician), the Board acknowledges the Veteran's accounts of chronic back pain as well as the private physician's July 2008 statement regarding Veteran's 4-6 weeks of incapacitating episodes. However, the doctor did not specifically state that such incapacitations necessitated bed rest. Most importantly what is lacking, though, is actual notification from a physician prescribing bed rest. Thus, it is not possible to establish that the Veteran actually had incapacitating episodes of intervertebral disc syndrome having a total duration of at least 4-6 weeks in a twelve month period during this appeal. As such the evidence does not illustrate doctor-prescribed bedrest due to incapacitating episodes for any period to justify a higher rating under DC 5243. See 38 C.F.R. § 4.71a. C. Analysis of Left Ear Hearing Loss Claim In an April 2004 rating action, service connection was granted for left ear hearing loss and a noncompensable evaluation was assigned under DC 6100. The Veteran appealed the initial evaluation assigned. Diagnostic code 6100 sets out the criteria for evaluating hearing impairment using puretone threshold averages and speech discrimination scores. 38 C.F.R. § 4.84. Numeric designations are assigned based upon a mechanical use of tables found in 38 C.F.R. § 4.85; there is no room for subjective interpretation. See Acevedo-Escobar v. West, 12 Vet. App. 9, 10 (1998); Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Audiometric results are matched against Table VI to find the numeric designation, then the designations are matched with Table VII to find the percentage evaluation to be assigned for the hearing impairment. To evaluate the degree of disability for service-connected hearing loss, the Rating Schedule establishes 11 auditory acuity levels, designated from Level I for essentially normal acuity, through Level XI for profound deafness. 38 C.F.R. § 4.85. The provisions of section 4.86 address exceptional patterns of hearing loss which are identified, as when each of the puretone thresholds at 1000, 2000, 3000, and 4000 Hz is 55 decibels or more, or when the puretone threshold is 30 decibels or less at 1000 Hz, and 70 decibels or more at 2000 Hz. 38 C.F.R. § 4.86. In situations where service connection has been granted for impaired hearing involving only one ear, and the Veteran does not have total deafness in both ears, the hearing of the non-service-connected ear is assigned a Roman numeral designation of I. 38 U.S.C.A. § 1160(a) (West 2002); 38 C.F.R. § 4.85(f). This is, however, subject to the provisions of 38 C.F.R. § 3.383. Under that regulation, if the service-connected ear is 10 percent or more disabling, the deafness of the nonservice-connected ear (whether total or partial) is considered in assigning the proper rating. See Veterans Benefits Act of 2002, Pub. L. 107-330, Title I, Section 103, 116 Stat. 2821, effective December 6, 2002, amending 38 U.S.C.A. § 1160, and 69 Fed. Reg. 48,148 (August 9, 2004), amending 38 C.F.R. § 3.383 effective to December 6, 2002. In July 2003, the Veteran underwent a VA examination. At that time puretone thresholds for the left ear were 10, 10, 5, 15, and 25, decibels at 500, 1000, 2000, 3000, and 4000 Hz, respectively. The results of the VA audiogram show an average puretone threshold of 14 decibels in the left ear with speech discrimination ability of 92 percent. Exceptional patterns of hearing impairment were not indicated. Table VI indicates a numeric designation of Level I hearing in the left ear, resulting in, according to Table VII, a noncompensable degree of left ear hearing loss. The paired organ rule is not for application, and the nonservice-connected right ear is assigned a Roman numeral designation of I. The Veteran submitted a private audiological examination conducted in April 2005. Puretone thresholds for the left ear were 15, 10, 15, 25, and 35, decibels at 500, 1000, 2000, 3000, and 4000 Hz. The results of the private audiogram show an average puretone threshold of 20 decibels in the left ear. The Board notes that, although testing was performed, the report does not provide the information necessary to rate the Veteran's left ear hearing loss disability. VA regulations require that an examination for hearing impairment be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. 38 C.F.R. § 4.85. Because the private report does not reflect use of the Maryland CNC Word List to evaluate speech discrimination, it may not be used determine the appropriate rating under the schedular criteria for left ear hearing loss. The remaining evidence of record is devoid of any additional post-service audiological examination reports. In this case, the Veteran's left ear hearing loss corresponds to a designation of level I hearing acuity in the service-connected left ear and level I hearing acuity in the non service-connected right ear. Such findings result in a noncompensable disability rating under DC 6100. The Board has considered the Veteran's contentions. Although there is no reason to doubt his difficulties, his disability is rated on the objective findings shown during audiological examination. The fact that his hearing acuity is less than optimal does not by itself establish entitlement to a compensable disability rating. To the contrary, it is clear from the Rating Schedule that higher ratings can be awarded only when loss of hearing has reached a specified measurable level. That level of disability has not been demonstrated here. Thus, a noncompensable evaluation is entirely appropriate for the Veteran's service-connected left ear hearing loss. Further, the Board acknowledges that the VA examiner did not elicit from the Veteran information regarding the functional effect of his left ear hearing loss. However, neither the Veteran nor his representative have alleged any prejudice caused by this failure. Martinak v. Nicholson, at 447, 455 (2007). Indeed, at no time during the current appeal has the Veteran asserted that this service-connected disability causes impairment of his daily activities and occupation. D. Analysis of Hemorrhoids Claim In an April 2004 rating action, service connection was granted for hemorrhoids and a noncompensable evaluation was assigned under DC 7336. The Veteran appealed the initial evaluation assigned. Under DC 7336, a noncompensable rating is warranted where hemorrhoids are mild or moderate in degree. A 10 percent rating is warranted where they are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating is warranted where there is persistent bleeding with secondary anemia, or with fissures. 38 C.F.R. § 4.114. During VA examination in July 2003, he gave a history of hemorrhoids since 1998 which were banded in 1998 relieving the majority of his hemorrhoids. He has had no procedures done since. He reported occasional bleeding of the hemorrhoids which lasts one to two times per week, but is not severe enough to require surgical procedure. He has had no other current treatment for his hemorrhoids. There were no signs of hemorrhoids on external examination and no evidence of bleeding. VA outpatient treatment records show that in June 2009 , the Veteran was evaluated for hemorrhoids with intermittent bleeding. During VA examination in April 2010, the examiner noted the Veteran history of banding procedure in 1998 for internal thromobsed hemorrhoids. Currently he has a problems with external hemorrhoids that bleed. Examination revealed a normal rectum and two large skin tags visible but no evidence of hemorrhoids and no rectal bleeding. The clinical diagnosis was history of hemorrhoids with banding procedure with normal examination. After considering the evidence of record pertaining to the Veteran's hemorrhoids, the Board finds that they are symptomatic to the extent that they cause some discomfort and periodic bleeding, but the evidence of record does not contain findings that suggest that they are more than moderate in severity. The evidence reflects that they are not large or irreducible, with excessive redundant tissue, evidencing frequent recurrences. There is also no evidence of persistent bleeding from the hemorrhoids of such severity as to result in anemia nor is there evidence of fissures and subsequent examination has shown that currently no hemorrhoids are present. Accordingly, the Board concludes that the criteria for a compensable rating for hemorrhoids are not met. The Board has considered rating the Veteran under closely related codes. Higher ratings are provided for impairment of sphincter control (DC 7332); stricture of the anus or rectum (DC 7333); prolapse of the rectum (DC 7334); and fistula in ano which is rated as analogous to impairment of sphincter control (DC 7335-7332). 38 C.F.R. § 4.114. However, absent clinical documentation of such findings the Veteran is not entitled to a compensable rating for his service-connected hemorrhoids under these additional diagnostic codes. E. Analysis of Perianal Abscess Claim In an April 2004 rating action, service connection was granted for perianal abscess and a noncompensable evaluation was assigned under DC 7335. The Veteran appealed the initial evaluation assigned. Under DC 7335 a fistula in ano is rated as impairment of sphincter control under DC 7332, which provides a noncompensable (0 percent) evaluation for impairment of sphincter control that is healed or slight without leakage; a 10 percent rating for constant slight, or occasional moderate leakage; and a 30 percent rating for impairment of sphincter control characterized by occasional involuntary bowel movements, necessitating wearing a pad. A 60 percent rating is assigned when there is extensive leakage and fairly frequent involuntary bowel movements and a 100 percent rating is assigned for complete loss of sphincter control. 38 C.F.R. § 4.114. The Veteran underwent a VA examination in July 2003, where he reported having a history of anal fistula starting in the 1980s. It was operated on in 1992 with repair of the defect. He has had no recurrence of his anal fistula since. He reported a good degree of sphincter control but some associated fecal leakage that was very mild and usually associated with a hard sneeze and did not require a pad. He has had no further recurrence of perianal fistula and no additional surgery or treatment. When examined by VA in August 2004, the examiner noted the Veteran had adequate sphincter tone. At a VA examination in April 2010, the Veteran's recounted his history of recurrent anal fistulas noting that he first developed an anal fistula in the 1980s that healed on its own. It returned in 1992 and was surgically repaired at that time. He developed a third fistula in 2006, which he drained himself. He was not currently receiving any treatment for it. The Veteran indicated a history of occasional fecal leakage. Examination revealed a normal rectum and two large skin tags visible but no rectal bleeding. There was no indication in the report confirming the presence of any leakage. The clinical diagnosis was history of anal fistula with normal exam. Considering the evidence of record, the Board finds that the criteria for the assignment of a compensable rating for the Veteran's anal fistula have not been met. As noted, the current regulation provides that a minimal 10 percent evaluation is warranted where there is leakage that is either constant and slight, or occasional and moderate. However, the cumulative objective evidence shows absolutely no objective findings of rectal leakage, fecal or otherwise was noted on physical examination by any VA examiner and sphincter tone was consistently described as normal. There was also no evidence of any current anal fissures or fistulas on examination. There is no basis for a compensable rating under DCs 7332, 7335. The Board has considered the possibility of other diagnostic codes, including DC 7333 (stricture of the anus or rectum) or DC 7334 (prolapse of the rectum). 38 C.F.R. § 4.114. Absent clinical documentation of such findings, the Veteran is not entitled to a compensable rating for his service-connected perianal abscess. F. Analysis of Erectile Dysfunction Claim In an April 2004 rating action, service connection was granted for erectile dysfunction and a noncompensable evaluation was assigned under DC 7522. The Veteran appealed the initial evaluation assigned. Under DC 7522, a 20 percent rating is warranted for penile deformity with loss of erectile power. 38 C.F.R. § 4.115b. Review of the claims file clearly shows that Veteran has an erectile dysfunction secondary to service-connected hypertension and/or low back disorders. However, this alone, without related deformity of the penis is insufficient for the granting of a compensable evaluation under DC 7522. The pertinent record is minimal and notably negative for any evidence documenting complaints, findings, or diagnosis pertaining to penile deformity. During VA examination in July 2003 the Veteran reported that he underwent a vasectomy in 1997, but no other trauma or surgery to his penis. He noted that he was able to achieve vaginal penetration with success and successful ejaculation, but at times had problems with delayed erection. He does take Viagra which helps. He has had no implants, pumps or injections. Genitourinary examination was declined by the Veteran. The clinical impression was erectile dysfunction. A genitourinary examination in August 2004, shows both testes were descended and symmetrical with no inguinal defect bilaterally. The penis was circumcised with no evidence of drainage or deformity. There was no indication of any deformity. Other evidence, contained in a June 2006 VA examination report shows examination of the genitals was normal. However during an April 2010 examination the Veteran indicated that he had very little capability of achieving an erection for intercourse and vaginal penetration was not possible despite the use of Viagra. Examination revealed the Veteran and erythematous skin with obvious fungal infection of the testicles and perineal area extending to the groin. Examination of the genitals themselves was normal. As the Veteran does not meet the minimal criteria for a compensable evaluation under this provision, a noncompensable evaluation is assigned. See 38 C.F.R. § 4.31. The Board can find no other diagnostic code that would be more appropriate in rating the Veteran's disability. There is no evidence that he has undergone removal of half or more of his penis, or that glans have been removed, such that would warrant consideration under DCs 7520 or 7521, respectively. Therefore, DC 7522 is most appropriate to rate this disability. Because the medical evidence does not reflect that the Veteran suffers from both penile deformity and loss of erectile power, the Board finds that he is properly evaluated at the noncompensable level for erectile dysfunction. Furthermore, the claims file shows he has also been awarded special monthly compensation due to loss of use of a creative organ. So the fact that he has erectile dysfunction has, to a large extent, already been taken into account. In any case, a compensable rating is not warranted under DC 7522. G. Analysis of Skin Claim In an April 2004 rating action, service connection was granted for skin disorders and a noncompensable evaluation was assigned under DC 7806. The Veteran appealed the initial evaluation assigned. Under DC 7806, provides that a 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation will be assigned where 20 to 40 percent of the entire body or 20 to 40 percent of exposed area is affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation will be assigned for dermatitis that covers more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or with constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118. The pertinent evidence consists primarily of clinical findings from VA examination in July 2003. At that time the Veteran gave a history of recurrent scalp sores. The sores were not constant or progressive and were treated with a topical antibiotic ointment. There were no systemic systems such as fever or weight loss and no neoplasms or urticaria. The Veteran also reported treatment for acne that started in 1995. He breaks out in small 3mm pustules on the face and neck. The condition is neither constant nor progressive and is treated with a topical application of Tetracycline gel, which has kept it under fairly good control. There were no side effect of the treatment and no systemic symptoms such as fever or weight loss or other phototherapy. Examination of the skin revealed two 3mm pustules on his scalp with mild surrounding erythema. There were no disfiguring scars, alopecia areata, hyperhydrosis or lymphadenopathy. About 5 percent of the Veteran's face and neck were affected with small 1-2 mm pustules with no surrounding erythema. The acne was superficial with open comedo that was not deep. There was no associated scarring on the face or neck. There was no impairment of occupational or activities of daily living. The clinical impressions were acne and folliculitis of the scalp. During VA examination April 2010, the Veteran complained of rash, scars, and itching. The Veteran reported that if he does use Selsun shampoo, he develops scalp sores. He also reported psoriasis on his knees. His current treatment included Selsun shampoo, oral tetracycline, and erythromycin solution and pads. Skin examination was essentially negative. The diagnosis was history of eczema. Based on this evidence, the Board finds that the Veteran's current disability picture resulting from his service-connected skin disorders meets or approximates the requirements for a 10 percent disability rating and no more. During VA examination in July 2003, clinical findings approximating the assignment of a 10 percent rating under the DC 7806 were noted. Although the VA examiner found only minimal symptomatology in the face and neck area, it affected an exposed surface area of 5 percent. Therefore, the Veteran meets the schedular criteria for a 10 percent rating. The remaining medical evidence reveals very few, if any, recent clinical findings attributable to the Veteran's skin disorders including when he underwent a VA examination in 2010, which noted that the skin disorders were not active and that there was no evidence of current skin problems. Therefore the Veteran does not meet the next higher evaluation under DC 7806, as there is no evidence that the skin conditions affect 20 percent or more of the entire body or exposed surface areas, or require systemic therapy such as corticosteroids, or other immunosuppressive drugs. Although the most recent VA examiner also noted the Veteran's reports of psoriasis, this skin condition appears to be an independent problem and not related to the service-connected skin disorders. In any event, none of the symptomatology which would allow for the assignment of a higher disability rating have been reported. While the Board has noted the Veteran's complaints, given the limited objective findings in the record, a disability rating in excess of 10 percent is not warranted. 38 C.F.R. § 4.118, DC 7806. Nor does the evidence show that the Veteran's skin disorders warrant a disability rating in excess of 10 percent under any other diagnostic codes available under 38 C.F.R. § 4.118 for assessing scars, as these codes require a showing of symptomatology not present in the Veteran's case. There are no medical findings of disfigurement of the head, face, or neck. There is also no evidence of tender, deep, unstable or painful scars, limitation of motion due to scars, or scars covering an area of 144 square inches. Thus, diagnostic codes for rating these manifestations are not for application. See 38 C.F.R. § 4.118 DCs 7800, 7801, 7802, 7803, 7804, 7805. At this time, the Board also notes that the schedule for rating skin disabilities under DC 7800-7805 were recently amended, effective October 23, 2008. See 78 FR 54708 (Sep. 23, 2008). However, the recent amendments are not applicable to the Veteran's appeal. Thus, no further consideration or action in this regard is needed. H. Analysis of Varicose Veins Claims In an April 2004 rating action, service connection was granted for varicose veins of the right and left lower extremities and noncompensable evaluations were assigned under DC 7120. The Veteran appealed the initial evaluations assigned. Under DC 7120, varicose veins that are visible or palpable yet asymptomatic are given a noncompensable evaluation. A 10 percent evaluation is warranted where there is intermittent edema of the extremity or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of the extremity or compression hosiery. A 20 percent evaluation is warranted where there is persistent edema, incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema. A 40 percent rating requires persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. Persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration warrant a 60 percent evaluation. A 100 percent rating is for application where there is massive board-like edema with constant pain at rest. 38 C.F.R. § 4.104. During VA examination in July 2003, the Veteran gave a 20-year history of varicose veins in both feet around the calcaneal area. He denied surgery or associated symptoms or pain. Exertion was not precluded by the condition and there was no current treatment. There was no evidence of Raynaud's phenomenon or post-phleblitic syndrome. There was no aching, fatigue, or abnormal sensations present in the leg at rest or after prolonged standing or walking. He reported occasional lymphadenma in his feet that was relieved by elevating his legs and resting. Examination revealed small superficial nonpalpable varicose veins around the calcaneal area of both feet, more present on the left compared to the right. There were no ulcers, edema, stasis, pigmentation, or eczema present. The clinical impression was nonpalpable various veins which did not affect the Veteran's employability. A VA examination in April 2010, revealed very few spider varicosities in the distal leg and ankle region. Pulses were normal. Based on the evidence, the Veteran's current disability picture resulting from his service-connected bilateral varicose veins meets or approximates the requirements for a 10 percent disability rating and no more. During VA examination in July 2003, clinical findings approximating the assignment of a 10 percent rating under the DC 7120 were noted. Although the VA examiner found only minimal symptomatology, the Veteran described occasional edema alleviated by elevation of his legs. Such a finding falls squarely within the criteria for a 10 percent schedular rating (and do not approximate the criteria for a 10 percent rating). After review of the evidence of record, the Board concludes that the Veteran's varicose veins of the right foot and left foot are most consistent with the criteria for a 10 percent evaluation than with the criteria for a higher evaluation. In this regard, the evidence shows that, while he experiences occasional swelling, it is not on a persistent basis. Accordingly, ratings higher than 10 percent for varicose veins of the right foot and left foot are not warranted. I. Extraschedular Consideration & Conclusion Finally, pursuant to 38 C.F.R. § 3.321(b)(1), an extraschedular rating is in order when there exists such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. Therefore, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the schedular evaluations in this case are not inadequate. The Veteran has not identified any factors which may be considered to be exceptional or unusual as to render impractical the application of the regular schedular standards and the Board has been similarly unsuccessful. As discussed above, there are higher ratings available for each of the Veteran's service-connected disabilities (adjudicated herein), but the required manifestations have not been shown in this case. Moreover, there is no evidence that any service-connected disability required hospitalization at any pertinent time during this appeal, and VA examinations are void of any finding of exceptional symptomatology beyond that contemplated by the schedule of ratings. Evidence in the claims file reveals that the Veteran is unemployed and while the Board is sympathetic to the difficulties his multiple service-connected disabilities cause him in maintaining employment, the evidence does not reflect that the average industrial impairment he suffers is in excess of that contemplated by the assigned evaluations, or that application of the schedular criteria is otherwise rendered impractical. The Board does not dispute the Veteran's contentions that his disabilities have caused him to alter his lifestyle and restrict his activities. Even so, such complaints have been taken into consideration in the decision to assign the current evaluations. In other words, the regular schedular standards contemplate the symptomatology shown. Accordingly, the Board finds that criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The only other evidence submitted in support of the claim are the Veteran's contentions. He has indicated that his service-connected disabilities have significantly limited his physical activities, and he is competent to describe readily visible and identifiable symptoms. However he is not competent to make medical determinations regarding the severity of his service-connected disabilities. It is not the Board's intent, in its discussion of the merits of this case, to in any way trivialize the severity of the Veteran's complaints or the sincerity of his beliefs concerning the gravity of his symptoms. But inasmuch as he is not competent to identify a specific level of disability as determined by the appropriate diagnostic codes, there is no means to increase the disability ratings based on the medical evidence currently of record, especially since none of the other codes of the rating schedule that might provide a basis for a higher rating apply. The Board has also reviewed the claim mindful of the guidance of Fenderson, supra. The current level of disability shown is encompassed by the ratings assigned and, with due consideration to the provisions of 38 C.F.R. § 4.7, higher evaluations are not warranted for any portion of the time period under consideration. ORDER Service connection for hearing loss of the right ear is denied. Service connection for chronic disability manifested by tooth pain is denied. Service connection for chronic bilateral foot disability manifested by pain is denied. Service connection for residuals of a cardiac arrest is denied. Service connection for residuals of pneumonia, manifested by granuloma, is denied. Service connection for a chronic adjustment disorder with depression is granted. An initial disability rating in excess of 30 percent for nephrolithiasis with recurrent urinary tract infections and voiding problems is denied. An initial disability rating in excess of 10 percent for residuals of low back injury, status post fusion L4-S1 with degenerative disc disease is denied. An initial compensable disability rating for left ear hearing loss is denied. An initial compensable disability rating for residuals of internal hemorrhoids, status post multiple banding is denied. An initial compensable disability rating for residuals of a perianal abscess and fistula, status post fistulectomy, with pruritis ani is denied. An initial compensable disability rating for erectile dysfunction associated with low back injury and hypertension is denied. An initial 10 percent disability rating for residuals of folliculitis, seborrhic dermatitis, and lichen simplex chronicus of the scalp is granted, subject to the regulations governing the award of monetary benefits. An initial 10 percent disability rating for varicose veins of the right foot is granted, subject to the regulations governing the award of monetary benefits. An initial 10 percent disability rating for varicose veins of the left foot is granted, subject to the regulations governing the award of monetary benefits. REMAND The Veteran alleges that service connection is warranted for GERD as a result of service. He also maintains in the alternative, that his GERD is due to medication taken for his service-connected musculoskeletal disabilities. When examined by VA in July 2003, the Veteran gave a history of heartburn since 1984. He reported that at that time he was treated for burning chest pain that he thought might be a heart attack. He experienced similar symptoms in 1992. Currently he has heartburn symptoms every three to four months and takes Maalox for relief. The clinical impression was heartburn. Also of record is a November 2010 medial statement from a private physician noting treatment of the Veteran since August 2010 for GERD (acid reflux). He noted that historically the Veteran's symptoms dated back to 1983 and that he continued to need treatment of it for better control. The record as it stands is currently inadequate for the purpose of rendering a fully informed decision as to the Veteran's appeal. The July 2003 VA record does not address with sufficient clarity the question of whether the Veteran has a chronic GERD related to service. In addition, none of the evidence of record sufficiently addresses the question of whether the Veteran has additional disability resulting from aggravation of his nonservice-connected GERD by any service-connected disability or the medications used to treat such disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (holding that 38 C.F.R. § 3.310 authorizes a grant of service connection not only for disability caused by a service-connected disability, but for the extent of additional disability resulting from aggravation of a nonservice-connected disability by a service-connected disability). Accordingly, a definitive medical opinion is needed. See Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this regard, the Board notes that, effective October 10, 2006, 38 C.F.R. § 3.310 was amended to conform to the Court decision in Allen. The RO will need to assess the secondary service connection claims on appeal with consideration of this regulatory amendment-particularly because the regulatory revision that adds a "baseline level of severity" requirement for the non-service-connected disability. See 38 C.F.R. § 3.310(b) (2010). Ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if pertinent). Finally, the Veteran has claimed entitlement to a TDIU rating. However, that claim is inextricably intertwined with the Board's grant of service connection for the acquired psychiatric disorder and with the potential grant of service connection for GERD (which is being remanded herein). That is, the potential exists for the TDIU issue to be affected by the grant of service connection once a disability rating and effective date have been assigned. In addition, the Board has assigned 10 percent ratings for the Veteran's service-connected skin disorder and bilateral varicose veins. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claims. Harris v. Derwinski, 1 Vet. App. 180 (1991). Thus, adjudication of the TDIU claim will be held in abeyance pending the assignment of both a disability rating and effective date for the service-connected psychiatric disorder, the potential assignment of a disability rating and effective date for GERD, as well as the assignment of compensable ratings and effective dates for the service connected skin disorder and bilateral varicose veins. Accordingly, the case is REMANDED for the following action: 1. Issue to the Veteran a corrective Veterans Claims Assistance Act of 2000 notice letter pertaining to the issue of entitlement to service connection for GERD, asserted to be secondary to service-connected disability. 2. After procuring the appropriate release of information forms where necessary, obtain records of any GERD treatment or evaluation that the Veteran has undergone. The Board is particularly interested in any pertinent treatment that he may have received from private physician, F. Oni, M.D. since August 2010. Document the attempts to obtain such records. If the AMC/RO is unable to obtain any pertinent evidence identified by the Veteran, so inform him and request that he obtain and submit it. If any records are unavailable, do not exist, or further attempts to obtain them would be futile, document this fact in the claims file. See 38 U.S.C.A. § 5103A(b). All such available documents should be associated with the claims folder. 3. Schedule the Veteran for an appropriate examination to determine the nature, extent, and etiology of any GERD. The claims folder must be made available to the examiner for review of the case. A notation to the effect that this record review took place should be included in the report. The examiner should elicit from the Veteran a detailed history regarding the onset and progression of relevant symptoms, and the examination report should include a discussion of the Veteran's documented medical history and assertions. All indicated tests and studies should be performed, and the examiner should review the results of any testing prior to completing the report. For any GERD diagnosed on examination, the examiner should provide an opinion addressing whether it is more likely than not (i.e., to a degree of probability greater than 50 percent), at least as likely as not (i.e., a 50/50 probability), or unlikely (i.e., a probability of less than 50 percent), that such disorder had its clinical onset in service or is otherwise related to active duty, including the in-service treatment for heartburn. If any currently diagnosed GERD cannot be regarded as having had its onset during active service, the examiner should explicitly indicate so. If GERD cannot be regarded as having had its onset during military service, the examiner should provide an opinion as to whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent), that a service-connected disability, (including the medications used to treat it) aggravates, contributes to, or accelerates his nonservice-connected GERD. If the GERD cannot be regarded as having been aggravated by any service-connected disability and/or its associated medications, the examiner should specifically indicate so and should provide rationale as to why that is. If aggravation is found, the examiner should identify the baseline level of severity of the nonservice-connected GERD to the extent possible. In answering these questions, the examiner should consider the order in which the Veteran's GERD and service-connected disability were diagnosed based on the evidence of record, if such a chronology is helpful in determining the etiological relationship between these two conditions. Note: The term "aggravated" in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. Complete rationale for all opinions should be provided in the examination report. 4. After completing the requested action, and any additional notification and/or development deemed warranted, readjudicate the claims remaining on appeal (entitlement to service connection for GERD and entitlement to TDIU). If the benefits sought on appeal remain denied, furnish the Veteran and his representative an appropriate supplemental statement of the case and give them an appropriate time period in which to respond. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claims. 38 C.F.R. § 3.655 (2009). He has the right to submit additional evidence and argument on the matters that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs