Citation Nr: 1305287 Decision Date: 02/13/13 Archive Date: 02/21/13 DOCKET NO. 10-36 358A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for oligodendroglia, also claimed as cancer condition (brain cancer). 2. Entitlement to service connection for a urinary tract disorder. 3. Entitlement to service connection for hypertension. 4. Entitlement to an initial rating in excess of 10 percent disabling for right shoulder degenerative joint disease (DJD). 5. Entitlement to an initial compensable rating for bilateral hearing loss. 6. Entitlement to an effective date earlier than November 22, 2010, for the grant of service connection for right shoulder DJD. 7. Entitlement to an effective date earlier than November 30, 2010 for the grant of service connection for bilateral hearing loss. 8. Entitlement to an effective date earlier than November 30, 2010 for the grant of service connection for tinnitus. REPRESENTATION Appellant represented by: Attorney Calvin Hansen ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran had active service from April 1969 to February 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a May 2010 rating decision of the Lincoln, Nebraska, regional office (RO) of the Department of Veterans Affairs (VA) which denied service connection for oligodendroglia (brain cancer). This matter also comes before the Board on appeal of a January 2011 rating decision of the Lincoln, Nebraska RO, which in pertinent part, denied service connection for a urinary tract disorder and hypertension and granted service connection for the following: a right shoulder DJD with an initial 10 percent rating assigned, bilateral hearing loss with an initial noncompensable rating assigned and tinnitus with an initial 10 percent rating assigned. The Veteran also appealed the effective dates for the grants of service connection assigned for the right shoulder DJD, bilateral hearing loss and right shoulder DJD. During the course of this appeal but prior to certification to the Board, the Veteran passed away in August 2011. In September 2011, after receiving notice of the Veteran's death, the RO withdrew the Veteran's pending appeals and provided the Veteran's surviving spouse with an Application for Accrued Benefits Due a Deceased Beneficiary (VA Form 21-601), advising her that she should use this form to file for entitlement to accrued benefits. In October 2011, the Veteran's surviving spouse submitted an application for Dependency and Indemnity Compensation (DIC), Death Pension and Accrued Benefits by a Surviving Spouse, (VA Form 21-534), as well as a completed VA Form 21-601 to the RO. In a June 2012 letter, the RO, now located at the VA RO and Pension Management Center in St. Paul, Minnesota, advised the Veteran's surviving spouse that it had received the VA Form 21-534 (DIC) claim, and advised that it was accepting this claim as a request to be substituted as the appellant for purposes of processing the Veteran's appealed claims on appeal to completion. The RO advised the appellant of the provisions in Section 212 of the Veterans' Benefits Improvement Act of 2008, Public Law 110-389 (VBIA 2008), providing for substitution of an eligible person who files a timely request for substitution (within one year of the claimant's date of death), and also advised that an eligible survivor may submit a substitution request by filing a VA Form 21-601 or VA Form 21-534 (such as was filed by the surviving spouse in this instance) or through any other communication indicating a desire to substitute for a deceased claimant. Thus, having granted this request, the appeal was continued with the surviving spouse as the appellant. See 38 U.S.C.A. § 5121A. The Board notes that in the June 2012 letter granting substitution, the RO listed appealed issues that would affect its decision on a pending DIC claim, to include prostate cancer, hypertension, hearing loss and arm limitation. The RO erroneously included prostate cancer as an appealed issue, when in fact this issue was not appealed to the Board and omitted the issue of entitlement to service connection for a urinary disorder, which is separate from the prostate cancer issue. In this regard, the Board notes that a claim for service connection for prostate cancer was adjudicated by the RO in a May 2011 decision. Prior to the expiration of the appeal period for this rating, the Veteran died on August [redacted], 2011, without submitting a notice of disagreement with this decision. As this matter is open and pending, but was not appealed to the Board prior to the Veteran's death, this matter is referred to the RO as an accrued claim. Additionally the Board notes that a claim for entitlement to service connection for cause of the Veteran's death has not yet been adjudicated by the RO and this is referred to the RO for appropriate action. The issue of entitlement to service connection for oligodendroglia (brain cancer), is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran died in August 2011. The appellant filed a proper claim for substitution in October 2011. 2. A preponderance of the evidence shows that a chronic urinary tract disorder was not manifested in service, and it is not otherwise related to active service. 3. A preponderance of the evidence shows hypertension did not have its clinical onset in service or within the first post service year, and it is not otherwise related to active service. 4. The Veteran's right (major) shoulder disability is not shown to result in limitation of major arm motion at shoulder level, nor is there ankylosis, malunion, recurrent dislocation, fibrous nonunion nor loss of the head of the humerus (flail shoulder). There is also no evidence of arthritis of the right shoulder resulting in occasional incapacitating exacerbations. 5. Throughout the entire appeal period, the Veteran has had bilateral hearing loss manifested by no worse than Level I hearing acuity in the right ear and Level I hearing acuity in the left ear. 6. On November 22, 2010, the Veteran filed an informal claim of entitlement to service connection for right shoulder DJD. 7. There is no communication submitted prior to November 22, 2010, that could be construed as an application to claim entitlement to service connection for right shoulder DJD. 8. On November 30, 2010, the Veteran filed an informal claim of entitlement to service connection for hearing loss. 9. There is no communication submitted prior to November 30, 2010, that could be construed as an application to claim entitlement to service connection for hearing loss. 10. On November 30, 2010, the Veteran filed an informal claim of entitlement to service connection for tinnitus. 11. There is no communication submitted prior to November 30, 2010, that could be construed as an application to claim entitlement to service connection for tinnitus. CONCLUSIONS OF LAW 1. A urinary tract disorder was not incurred in or aggravated by the Veteran's active duty service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.159, 3.303. (2012). 2. Hypertension was not incurred in or aggravated by active service, and neither may it be presumed to have been incurred or aggravated therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303 , 3.307, 3.309(a) (2012). 3. The criteria for an initial rating in excess of 10 percent for right shoulder degenerative joint disease (DJD) have not been met. 38 U.S.C.A. §§ 1155 , 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.3 , 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2012). 4. The criteria for an initial compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155 , 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (2012). 5. The criteria for an effective date prior to November 22, 2010, for the award of service connection for right shoulder DJD have not been met. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.400 (2012). 6. The criteria for an effective date prior to November 30, 2010, for the award of service connection for bilateral hearing loss have not been met. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.400 (2012). 7. The criteria for an effective date prior to November 30, 2010, for the award of service connection for tinnitus have not been met. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102 , 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a November 2010 letter, sent prior to the initial February 2010 rating decision, advised the Veteran of the evidence and information necessary to substantiate his service connection claims for high blood pressure, right shoulder disorder and urinary disorder, as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the letter advised the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. A January 2011 letter advised the Veteran of the evidence and information necessary to substantiate his service connection claim for hearing loss. The rating adjudicating this claim for hearing loss was also dated in January 2011, with readjudication via the statement of the case accomplished in August 2011. The increased rating and earlier effective date claims arise from a disagreement with the initial evaluations and effective dates following the grants of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Likewise, as the effective date issues, any defect in the notice is not prejudicial given that the matters arise from the initial grant of service connection. See Hartman, supra, Dunlap, supra. Further, VCAA notice error is not presumed to be prejudicial. See Shinseki v. Sanders, 556 U.S. 396, 129 S. Ct. 1696, 173 L.Ed.2d 532 (2009). Neither the Veteran nor his representative has asserted any specific prejudice in any of the VCAA notice given. The rating decision and the statement of the case (SOC) set forth detailed reasons and bases as to why the Veteran's claims was denied as well as the evidence that is needed to prove the claims. Thus any error in the VCAA notice is shown to be harmless. Relevant to the duty to assist, the Veteran's service treatment and personnel records, VA treatment records, and private treatment records have been obtained and considered. The Board has reviewed the Veteran's Virtual VA claims file. The appellant has not identified any additional, outstanding records necessary to decide this pending appeal. Additionally, the Veteran was afforded a VA examination in December 2010 in order to adjudicate these claims. In this regard, the Board finds that the proffered opinions regarding the severity of his right shoulder disability and the etiology of the claimed hypertension and urinary tract disorder were based on an interview with the Veteran, a review of the record, and a full examination. As such, the Board finds that the opinions proffered by the VA examiner is sufficient to decide the claims. In regards to the hearing loss claim, although no formal VA examination was obtained, the November 2010 private audiologist's report provided sufficient information upon which to assign a rating for the hearing loss disability. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the appellant in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the appellant will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis Service Connection Claims Applicable Law and Regulations The Board has reviewed all the evidence in the claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). Also, the Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Generally, service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b) (2012). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status will not always constitute competent medical evidence. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). 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); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Urinary Tract Disorder The Veteran claimed entitlement to service connection for a urinary tract disorder as directly related to service, and alleged that they are due to discolored urine treated inservice. The Board is considering this matter on a direct basis only and is not considering whether service connection for any urinary symptoms associated with prostate cancer is warranted, as the prostate cancer issue has been referred to the RO for adjudication. Service treatment records show normal genitourinary examination on entrance examination in April 1968. No urinary abnormalities are shown until May 1970, when he was treated for a five day history of sore throat, anorexia, weakness and brown urine. Physical examination revealed findings of brown urine, along with other multiple findings including a fever of 100 degrees, pustular pharyngitis, cervical lymphadenopathy, hepatic tenderness with percussable liver. The diagnosis was probably infectious mono or possibly anicterus hepatitis. Following transfer to U.S.S. America for further treatment, he was diagnosed with tonsillitis, with history that included sore throat, anorexia, chest pain and brown (amber) urine. Examination was significant for a negative urinalysis and normal urine bile test. Following hospital course, he was discharged. No further findings of any urinary abnormalities are shown in the service treatment records. His February 1973 separation examination revealed normal genitourinary examination. Post service, there is no evidence of any urinary issues shown prior to December 2009, when he was under treatment for his brain cancer. The treatment records from December 2009 revealed that he also had a diagnosis of prostate cancer with treatment canceled once the brain cancer was diagnosed. He also had symptoms of urinary output of a slow outlet obstruction and a chronic Foley catheter (Foley). The doctor was unsure as to whether the Veteran's need for a Foley was due to outlet obstruction from prostate cancer or due to a spastic bladder from his recent surgery of his brain tumor. Another record from December 2009 addressing low back pain noted the Veteran to also have a history of kidney stones. He was hospitalized from December 2009 to January 2010 in the "IRU" with discharge diagnoses that included urinary tract infection (UTI), with a urinary consult that noted symptoms including urinary retention. His Foley was removed and replaced, and the UTI was treated. A radiation consult from the end of December 2009 noted the history of recent UTI. The remainder of the records from January 2010 through March 2010 addressed treatment for the brain cancer with radiation, with a notation on January 18, 2010 revealing that the Foley was removed with some ongoing problems with dribbling noted. On January 25, 2010, he denied any infectious symptoms. The oncology records from February 2010 to March 2010 disclosed no evidence of a chronic bladder disorder. The report of a December 2010 VA examination for urinary tract infection revealed the Veteran was claiming this condition as due to the multiple times he had "brown" urine during service. The examiner reviewed his history and evidence of record in the claims file. The Veteran described having discolored urine, either brown or amber in color, beginning in active duty. He also recalled having difficulty initiating his urinary stream, some straining and hesitancy. He stated that he underwent evaluation for this but no specific diagnosis was rendered. He also indicated that after his discharge from service in 1972 he was followed by primary care doctors in the 1970's. At that time he was said to have undergone urologic evaluation and was found to have some obstructive symptoms for which he underwent dilation procedures. His wife thought he might have undergone 2 such procedures in the past. He indicated it had been 10-20 years since such procedures. The examiner found no documentation of chronic UTI's in the past. The Veteran stated that it had been over a year since he had a UTI. The examiner noted that between November 2009 and December 2009 while hospitalized for brain cancer with resection, the Veteran underwent catheterization and had UTI at the time. There were no UTI's since hospitalization. He was also noted to be diagnosed with prostate cancer with no surgery for this due to the brain tumor. His current urology symptoms included urinary frequency, nocturia 4-5 times a night. He had some urinary urgency, incontinence and leakage, and wore a pad for incontinence which developed during the November 2009 timeframe he was treated for the brain tumor. Currently he described good flow but some continued problems with hesitancy and straining. He had some post void dribbling and some overall fatigue. He was noted to have undergone cystoscopies that included retrieval of a renal stone. There was no documentation of the dilation procedures or other urological procedures in the records that may have taken place in the 1970's, 1980's or 1990's. The examiner reviewed the service treatment records showing some brown or amber urine around May 1970. Although it was noted 2 times in service, it was related to the same incident when he was experiencing a febrile illness, including tonsillitis for which he received antibiotic treatment. The examiner could find no specific ongoing evaluation or treatment in regards to any urinary tract condition while on active duty, only the notation historically of the noted brown urine. There was no diagnosis of UTI or any other urinary tract condition or even symptoms in the military suggestive of obstruction. Further, this evaluator could find no evidence of any urological diagnosis documented in his claims file that occurred within one year of release from active duty. Again his history was noted to be significant for the prostate cancer, urinary stones, fatigue, urinary leakage and incontinence, and urinary retention which hasn't caused any UTI's. He had no general symptoms due to genitourinary disease such as anorexia, nausea, vomiting, fever, chills, lower abdominal or pelvic pain. Examination revealed normal bladder, and the rest of the genitourinary examination was normal, except for the prostate which was enlarged. The diagnosis was insufficient clinical evidence to warrant a diagnosis of any acute or chronic UTI. The examiner gave an opinion that the condition/disability of UTI was less likely as not caused by or the result of multiple times the Veteran had brown urine in service. At present he had not demonstrated evidence of chronic recurrent UTI. It had been more than one year since he had any UTI; and such infection was associated with his hospitalization and catheterization. He did describe some symptoms of bladder outlet obstruction as having occurred on active duty or within one year of discharge. The examiner speculated that if private treatment records reflecting urological conditions for which he was seen for shortly after service were available, this issue could be revisited. However based on review of the records in the claims file, the examiner was unable to support a finding that the Veteran had onset of urological condition on active duty that had a persistence and continuity of symptoms until present. Therefore this examiner opined that the Veteran did not demonstrate a UTI due to having brown or amber urine during active duty. Where a medical expert has fairly considered all the evidence, his or her opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion. Wray v. Brown, 7 Vet. App. at 493. The Board does, in fact, adopt the VA examiner's opinion on which it bases its determination that service connection for a urinary tract disorder is not warranted. Since the VA physician's opinion was based on a review of the pertinent medical history, and was supported by sound rationale, it provides compelling evidence against the appellant's claim. The Board emphasizes that the VA medical examiner provided a valid medical analysis to the significant facts of this case in reaching a conclusion. The VA examiner did not only provide data and conclusions, but also provided a clear and reasoned analysis, that the United States Court of Appeals for Veterans Claims (Court) has held is where most of the probative value of a medical opinion comes is derived. See Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008); see also Wray, supra. In providing the opinion, the examiner explained the episodes of urinary manifestations of brown or amber urine documented in service as being temporary incidents that took place in conjunction with a febrile illness with no evidence of any other urinary manifestations shown in service. The examiner also discussed the lack of documented record of treatment for the alleged bladder outlet obstructions shortly after service, and addressed the lack of evidence to support the Veteran's claim of having dilation treatment shortly after service. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). In regards to the UTI treated during the Veteran's hospitalization for cancer treatment in December 2009, this was noted to have been acute and transitory, without evidence of a chronic disability of urinary tract infections a year after this treatment. The Board notes that there is no medical evidence that directly contradicts the conclusions of this examiner, but the medical records generally just show the absence of chronic urinary tract infections after 2009, and no evidence of the outlet obstructions reported by the Veteran. The Board therefore places greater weight on the VA opinion that finds that a chronic urinary tract disorder did not have an onset during active service. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches"). It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. at 433. But, we are mindful that we cannot make our own independent medical determinations, and that we must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In evaluating the ultimate merit of this claim, the Board ascribes the greatest probative value to the medical opinion provided by the VA physician who provided the written opinion in December 2010, which has not been contradicted by other medical evidence. Thus, the probative and objective medical opinion of record demonstrates that the Veteran did not have a chronic urinary tract disorder related to his period of active military service. A clear preponderance of the evidence that the Veteran's urinary manifestations of discolored urine present during service was acute and transitory, without residuals, and is against a finding that a chronic urinary disorder began in or was otherwise related to active military service. To the extent the Veteran was claiming continuity of urinary problems since service, his statements are not credible. The urinary disorder in service was related to an acute febrile illness that resolved with the illness. Subsequent testing revealed normal genitourinary system. There was no mention of genitourinary problems on the separation examination and no treatment for urinary disorder until many years after service. The Board does not find it likely that urinary problems continued after the acute onset in service but were not otherwise reported by the Veteran or noted by medical personnel during follow-up treatment and examinations. In regards to the lay evidence suggesting treatment for urinary obstruction shortly after service, this is not supported by any clinical evidence and there is no evidence suggesting that it would provide a link between post service disability and the findings in service. To the extent the Appellant/Veteran is claiming that urinary problems in service are etiologically related to the post service urinary tract disorder, they are not shown to have the medical expertise to do so. While the Veteran is competent to report what comes to him through his senses, he does not have medical expertise. See Layno v. Brown, 6 Vet. App. 465 (1994). And although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as shortness of breath or varicose veins, he is not competent to provide evidence as to more complex medical questions, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). See Buchanan v. Nicholson, 451 F.3d 1331, 1336-7 (Fed. Cir. 2006) (holding the Board is obligated to, and fully justified in, determining whether lay testimony is credible in and of itself, and that the Board may weigh the absence of contemporary medical evidence against lay statements). The evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The preponderance of the evidence of record is against the claim for service connection for a urinary tract disorder, and this claim must be denied. Hypertension The Veteran contended in his claim that he was diagnosed with hypertension in service, and was entitled to service connection for this disease. In addition to the general provisions governing service connection set forth above, special presumptions exist in regards to claims for cardiovascular-renal disease including hypertension. Where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and certain chronic diseases, to include hypertension, becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101 , 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Service treatment records revealed normal cardiovascular examination with his blood pressure 114/68. In January 1971 he was treated for a history of nosebleeds for 1 week with a blood pressure of 142/96 noted in the consult request. He reported a doubtful family history of increased blood pressure. On the consultation he complained of episodes of epistaxis 1-2 times a month for several years, since age 16, with a small amount of bleeding that stopped spontaneously. He had a history of recent cold. Examination focused on the nose, with no active bleeding, and a blood pressure of 120/70 was taken. None of the other service treatment records revealed any evidence of hypertension or high blood pressure. His separation examination of February 1973 showed a blood pressure of 130/80. Post service records include no findings of any elevated blood pressure or hypertension within one year after discharge from service. Hypertension is not shown to be a diagnosis prior to 2009, when records from December 2009 documenting newly diagnosed brain cancer included a past medical history significant for hypertension, and blood pressure readings of 128/84. Other blood pressure readings from December 2009 were 137/79. Records from the Veteran's hospital treatment for brain cancer from December 2009 to January 2010 included the diagnosis of hypertension, with the discharge record describing blood pressure that was controlled and medications were changed. Radiation therapy records from January 2010 revealed his blood pressure was 125/72 and 101/64. His vitals were repeatedly described as normal in the radiation records from February 2010. In March 2010 his blood pressure was 122/76 and 118/74. The report of a December 2010 VA examination for hypertension included claims file review, with the examiner noting that service treatment records showed normal blood pressure on entrance in 1968 and on separation in March 1973, with the lone elevated blood pressure in service shown to be in January 1971 when it was 142/96. The examiner noted that there was no evidence of persistent elevated blood pressures that would meet any diagnostic criteria for hypertension in service. Further there was no documentation for review of the Veteran having elevated blood pressures or hypertension diagnosed within one year of release from service. Although the Veteran stated he was diagnosed with hypertension and started on medications shortly after his release from service, there was no documented record of this. Further, although he stated he was on 2 separate different medications for blood pressure, he did not have a medication list and did not remember the names or dosing of medication. His family members likewise lacked such information. His medical history was negative for hypertensive renal disease, strokes/TIA, nosebleeds or headaches due to hypertension. He had no heart disease. On examination his blood pressure was 112/64 after 3 readings. His heart size was normal. The examiner opined that hypertension was less likely as not caused by or the result of service. The rationale was that review of the service treatment records did not indicate any documented blood pressures that would meet the diagnostic criteria for hypertension. There was only one recorded blood pressure reading of 142/96 that would be considered hypertensive. However there was no evidence of sustained persistent blood pressures over 140 or diastolic blood pressures over 90 to support a diagnosis of hypertension as having begun in active duty. Further there was no documentation or treatment of hypertension beginning in one year following release from active military duty. Where a medical expert has fairly considered all the evidence, his or her opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion. Wray, 7 Vet. App. at 493. The Board does, in fact, adopt the VA examiner's opinion on which it bases its determination that service connection for hypertension is not warranted. Since the VA physician's opinion was based on a review of the pertinent medical history, and was supported by sound rationale, it provides compelling evidence against the appellant's claim. The Board emphasizes that the VA medical examiner provided a valid medical analysis to the significant facts of this case in reaching a conclusion. The VA examiner did not only provide data and conclusions, but also provided a clear and reasoned analysis, that the United States Court of Appeals for Veterans Claims (Court) has held is where most of the probative value of a medical opinion comes is derived. See Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008); see also Wray, 7 Vet. App. at 493. In providing the opinion, the examiner explained the elevated blood pressure of 142/96 documented in service as being an isolated episode, as there was no evidence of sustained persistent blood pressures over 140 or diastolic blood pressures over 90 to support a diagnosis of hypertension as having begun in active duty. The examiner also discussed the lack of documented record of hypertension diagnosed within one year of service, and addressed the lack of evidence to support the Veteran's claim of being on medication shortly after service. See Prejean, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board notes that there is no medical evidence that directly contradicts the conclusions of this examiner, but the records generally just show the presence of a diagnosis of hypertension beginning in 2009, without discussion of etiology. The Board therefore places greater weight on the VA opinion that finds that hypertension did not have an onset during active service. See Owens, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches"). It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others. Evans, 12 Vet. App. 22, 30 (1998); see also Rucker, 10 Vet. App. 67, 74 (1997), citing Colvin, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In evaluating the ultimate merit of this claim, the Board ascribes the greatest probative value to the medical opinion provided by the VA physician who provided the written opinion in December 2010, which has not been contradicted by other medical evidence. Thus, the probative and objective medical opinion of record demonstrates that the Veteran did not have hypertension related to his period of active military service. A clear preponderance of the evidence is against a finding that the Veteran's hypertension or other cardiovascular disability was present during or otherwise related to active military service. The probative evidence is also against finding that the Veteran's hypertension began within the presumptive one year period following service. A layperson, however, is generally not deemed competent to opine on a matter that requires medical knowledge, such as the question of whether a current disability has been incurred in active service or caused or aggravated by another disability. While the Veteran is competent to report what comes to him through his senses, he does not have medical expertise. See Layno, 6 Vet. App. 465 (1994). And although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as shortness of breath or varicose veins, he is not competent to provide evidence as to more complex medical questions, as is the case here. See Woehlaert, 21 Vet. App. 456 (2007). The Veteran is competent to state that he was diagnosed with hypertension in service, but is not shown credible in this instance He was seen for a blood pressure reading in service and hypertension was not diagnosed. It seems likely that he misunderstood the distinction between the examination for hypertension and a diagnosis of hypertension. See, Robinette v. Brown, 8 Vet. App. 69 (1995). The evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b) ; 38 C.F.R. § 3.102. The preponderance of the evidence of record is against the claim for service connection for hypertension, and this claim must be denied. Increased rating for right shoulder DJD in excess of 10 percent disabling Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2012). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Additionally, although regulations require that a disability be viewed in relation to its recorded history, 38 C.F.R. §§ 4.1 , 4.2, when assigning a disability rating, it is the present level of disability which is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation during the relevant rating period. Fenderson v. West, 12 Vet. App. 119 (1999). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2012). Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14 (2012). However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 (2012), should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2012). For the purpose of rating disability from arthritis, the spine is considered a major joint. 38 C.F.R. § 4.45 (2012). The appellant argues that the Veteran's right shoulder DJD disability was more severe than is represented by the currently assigned initial 10 percent rating assigned under Diagnostic Codes (DC's) 5010-5201. The Board shall consider these and any other appropriate DC's. Upon review of the evidence of record, the Board concludes that a rating in excess of 10 percent for the right shoulder disability is not warranted for any time since the Veteran filed his initial claim. The service treatment records and the December 2010 VA examination report, described below, indicate that the Veteran was right-handed. Thus, his service-connected right shoulder was his major extremity. Under DC 5010, degenerative or traumatic arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, DC 5003 and 5010 (2012). The 10 and 20 percent ratings under these provisions will not be combined with ratings based on limitation of motion, nor are they to be combined with rating conditions listed under DCs 5013 to 5024, inclusive. DC 5003, Notes 1 & 2. Under DC 5201, a 20 percent evaluation is assigned for limitation of major arm motion at shoulder level. 38 C.F.R. § 4.71a , DC 5201. When there is limitation of motion midway between the side and shoulder level, a 30 percent rating is again warranted for limitation of motion of the minor arm, and a 40 percent rating is warranted for limitation of motion of the minor arm to 25 degrees from the side. Id. Under DC 5202, for impairment of the humerus in the major arm, a 20 percent rating is assignable when there is malunion, with moderate deformity and a 30 percent rating is assignable when there is malunion, with marked deformity of the arm. 38 C.F.R. § 4.71a , DC 5202 (2012). Also under DC 5202, for recurrent dislocation of the arm at the scapulohumeral joint, a 20 percent rating is assignable with infrequent episodes, and guarding of movement only at shoulder level. A 30 percent rating is assignable where there are frequent episodes and guarding of all arm movements. Id. Fibrous union of the humerus of the major arm warrants a 50 percent rating; nonunion (false flail joint) warrants a 60 percent rating; and loss of the head of the humerus (flail shoulder) warrants a 80 percent rating. Id. Under 38 C.F.R. § 4.71a , DC 5203 (2012), for impairment of the clavicle or scapula in the major or minor arm manifested by dislocation, a 20 percent rating is warranted. For nonunion with loose movement, a 20 percent rating is assignable when involving the major arm. Id. For nonunion without loose movement, and for malunion, a 10 percent rating is assignable. Id. Under DC 5200, ankylosis of the scapulohumeral articulation of the major upper extremity is rated 30 percent disabling when favorable (abduction to 60 degrees, can reach mouth and head); 40 percent disabling when intermediate (between favorable and unfavorable); and 50 percent disabling when unfavorable (abduction limited to 25 degrees from side). 38 C.F.R. § 4.71a, DC 5200 (2012). Normal range of shoulder motion is forward extension (flexion) from 0 to 180 degrees; shoulder abduction from 0 to 180 degrees; internal rotation from 0 to 90 degrees; and external rotation from 0 to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. See 38 C.F.R. § 4.71 , Plate I (2012). Available post service medical records focus on treatment for brain cancer from December 2009 to March 2010, with no findings pertinent to the right shoulder. The only pertinent evidence is shown to be the report of a December 2010 VA examination. This examination report revealed the Veteran to describe intermittent problems with his shoulder over the years. Currently he had pain, stiffness, and some achiness to the right shoulder. He described flare-ups of moderate severity every other week, lasting from hours to 1-2 days. These flare-ups were precipitated by increased activities involving the shoulder including overhead reaching, activities against resistance, or repetitive activities. He had no history of injections, or surgery of any type involving the right shoulder. He treated with over the counter medications of Tylenol which helped without side effect. Other alleviating factors included rest, heat, ice and activity limitation. He was presently not working due to his brain tumor. He had worked as a welder for 32 years. He had no time lost from work due to his shoulder. His course since onset was progressively worse. He was right hand dominant. There were no constitutional or incapacitating symptoms from arthritis. On examination his range of motion from 0 degrees was 180 degrees forward elevation (flexion) (with tenderness beginning at 170 degrees), 175 degrees abduction (with tenderness beginning at 160 degrees), 85 degrees external rotation (with tenderness beginning at 80 degrees), and 90 degrees internal rotation (with tenderness beginning at 85 degrees). There was some increase in pain without additional weakness, fatigability, incoordination, lack of endurance or additional loss of motion with repetitive use. The examiner could not express additional limitation due to repetitive use during flare-up without resorting to speculation. X-ray showed mild degenerative changes right shoulder. The diagnosis was right shoulder DJD, with significant affects on occupation, with problems lifting and carrying, difficulty reaching and pain. The resulting work problems were being assigned different duties. The effects on activities of daily living included mild effects on chores, exercise, recreation, travel, dressing and driving. There were moderate effects on sports and no effects on shopping, toileting and grooming. He was retired in November 2009 secondary to his brain tumor. The evidence does not show that the Veteran's right (major) arm motion was limited to motion at shoulder level as required for a higher rating of 20 percent under DC 5201. As indicated on the most recent VA examination in 2010, with consideration of the point at which tenderness began, flexion of the right shoulder was to 170 degrees, abduction was to 160 degrees, external rotation was to 80 degrees, and internal rotation was to 85 degrees. Clearly such movements, even when factored for the endpoint where tenderness began were not reflective of motion limited to shoulder level. As such, a higher rating under DC 5201 is not warranted. There is also no evidence that the right shoulder disorder warranted a 20 percent rating under DC 5003-5010, as there is no evidence of incapacitating exacerbations, and there was some loss of motion present as noted above, albeit noncompensable. Further, the Board acknowledges that there was objective evidence of pain following repetitive motion, but there was no additional limitations after three repetitions of range of motion as reported on VA examination in February 2009. The Board observes that even if the Veteran had exhibited additional limitation upon repetitive motion, a higher rating would still not be warranted in this case because the 20 percent rating assigned adequately compensates him for any functional impairment that he experiences due to his left shoulder disability. See DeLuca, 8 Vet. App. 202. The Board has also considered the application of DC 5200 for disabilities involving ankylosis of the scapulohumeral articulation; DC 5202 for other impairment of the humerus to include recurrent dislocation, fibrous union, non union or flail shoulder; and DC 5203 impairment of the clavicle/scapula to include nonunion with loose movement. However, there is no evidence of ankylosis, recurrent dislocation, fibrous union, non union, flail shoulder, or nonunion of the clavicle or scapula with loose movement involving the right shoulder joints. No such findings for the right shoulder are shown in the December 2010 examination report or elsewhere in the records. Therefore, consideration of an increased disability rating under such codes is not warranted. The Board finds no provision upon which to assign a rating greater than 10 percent for the Veteran's right shoulder disability. Aside from alleging that a rating greater than 10 percent disabling was warranted, the Veteran forwarded no lay contentions regarding the severity of his right shoulder disorder. Generally lay witnesses such as the Veteran are competent to report having experienced constant pain, as it is within lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir.2006). However, in determining the actual degree of disability, and given the lack of lay statements about the severity of such disability, the findings of the December 2010 examination, which factored his subjective complaints of pain, is most probative of the degree of the Veteran's impairment. In light of the above, the Board finds that entitlement to an evaluation in excess of 10 percent for the Veteran's service-connected right shoulder disability is not warranted at any point in the appeal period. The Board has considered whether the benefit of the doubt rule applies to the present appeal. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). However, a preponderance of the evidence is against a higher evaluation; thus, this rule does not apply and the claim for an initial increased evaluation for right shoulder disability must be denied. Finally, the Board had considered entitlement to an extraschedular evaluation, but finds that one is not merited in this case. The record does not reflect that the Veteran's right shoulder disability was so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds that the rating criteria used to evaluate the Veteran's service-connected right shoulder disability reasonably describe his disability level and symptomatology and he has not argued to the contrary. The criteria, 38 C.F.R. § 4.71a, DC 5010, 5301-5303, reasonably describe the Veteran's right shoulder disability level and symptomatology, and consequently his disability level is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate. For this reason, the Veteran's disability picture is contemplated by the rating schedule and no extraschedular referral is required. 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Fenderson, supra. However, the evidence reflects that his symptoms have remained constant throughout the course of the period on appeal and, as such, staged ratings are not warranted. Increased (compensable) rating for hearing loss Service connection for hearing loss was granted by the RO in a January 2011 rating decision which assigned an initial noncompensable rating. The Veteran appealed this decision. The assignment of disability ratings for service-connected hearing impairment is derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The severity of a hearing loss disability is determined by applying the criteria set forth at 38 C.F.R. § 4.85. Under these criteria, evaluations of bilateral hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000 and 4000 cycles per second. To evaluate the degree of disability from defective hearing, the rating schedule establishes eleven auditory acuity levels from Level I for essentially normal acuity through Level XI for profound deafness. 38 C.F.R. § 4.85. To evaluate an individual's level of disability, Table VI is used to assign a Roman numeral designation for hearing impairment based on a combination of the percent of speech discrimination and the pure tone threshold average. 38 C.F.R. § 4.85(b). Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment for each ear. 38 C.F.R. § 4.85(e). If the puretone threshold at each of the specified frequencies of 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, an evaluation can be based either on Table VI or Table VIa, whichever results in a higher evaluation. 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz , the Roman numeral designation for hearing impairment will be chosen from either Table VI or Table VIa, whichever results in the higher numeral, and that numeral will then be elevated to the next higher Roman numeral. 38 C.F.R. § 4.86(b). Available post service medical records primarily focus on treatment for brain cancer from December 2009 to March 2010, with no findings pertinent to the Veteran's hearing loss, and he did not undergo a VA examination to address his hearing loss prior to his death. The only pertinent evidence is shown to be the report of a November 2010 private audiologist's report which described the Veteran as having presented with chief complaints of hearing loss and tinnitus. The Veteran reported difficulty understanding conversations in difficult listening situations. Occupationally he worked in manufacturing since service, and wore hearing protection. He denied any other ear symptoms such as ear pain, drainage, rapidly progressive hearing loss, balance or dizziness problems or sensitivity to loud sounds. The audiologist reviewed a copy of an audiogram taken in late October 2010, also attached. This showed him to have moderate high frequency sensorineural hearing loss (SNHL) bilaterally. His maximum word recognition scores were 96 bilaterally. His acoustic reflexes were consistent with hearing loss. Pure tone averages for 1000 through 4000 Hertz were interpreted and calculated to be 51.25 decibels on the right and 45 decibels on the left. The Veteran was recommended to wear hearing aids and avoid noise exposure. These findings from the November 2010 private audiologist's report yield a numerical designation of Level I in the right ear and Level I in the left ear. Such designations, when applied to Table VII, results in a zero percent rating under Diagnostic Code 6100. The Board notes that in Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007), the Court noted that VA had revised its hearing examination worksheets in April 2007 to include the effect of a veteran's hearing loss disability on occupational functioning and daily activities. The Court also noted, however, that even if an audiologist's description of the functional effects of a veteran's hearing disability was somehow defective, the veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. While November 2010 private audiologist's report did not discuss in detail the functional effects on occupation other than to note that he wore hearing protection at work, the Veteran did report the functional effects of his hearing in terms of difficulty understanding conversations in difficult listening situations, which presumably would include an occupational environment. Accordingly, this report is adequate for rating purposes. In sum, an initial compensable evaluation is not warranted for the Veteran's bilateral hearing loss disability under 38 C.F.R. § 4.85, Diagnostic Code 6100. As noted above, the audiometric test results generate a zero percent disability rating. See 38 C.F.R. § 4.85, Tables VI and VII. The Board also finds that, in light of the Veteran's test scores, the Veteran did not have an exceptional pattern of hearing loss as defined by 38 C.F.R. § 4.86. Accordingly, the Board finds that entitlement to an initial compensable rating for bilateral hearing loss is not warranted. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The Board has also considered whether the Veteran's hearing loss disability presented an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extraschedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology from his hearing loss, and provide for higher ratings for more severe symptoms. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun, 22 Vet. App. 111, 115 (2008). In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against this portion of the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Earlier effective date The Board notes that the assignment of effective dates of awards is generally governed by 38 U.S.C.A. § 5110 and 38 C.F.R. § 3.400. Except as otherwise provided, the effective date of an evaluation and an award of pension, compensation or dependency and indemnity compensation based on an original claim or a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. The "date of the claim" means the date of the application based upon which benefits are awarded, not the original claim for service connection. See Sears v. Principi, 16 Vet. App. 244, 246-47 (2002), aff'd, 349 F.3d 1326 (Fed. Cir. 2003). In this context, it should be noted that the provisions of 38 U.S.C.A. § 5110 also refer to the date an application is received. While the term "application" is not defined in the statute, the regulations use the terms "claim" and "application" interchangeably, and they are defined broadly to include "a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." 38 C.F.R. § 3.1(p) , 3.155; Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). If a claim is received within 1 year after separation from service, the effective date corresponds to the day following separation from active service or date entitlement arose. 38 C.F.R. § 3.400 (a)(2). Otherwise, the effective date corresponds to the date of receipt of claim, or date entitlement arose, whichever is later. Id. Any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA from a claimant may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if the formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of the receipt of the informal claim. 38 C.F.R. § 3.155 . Initially, the Board notes that a claim of service connection was not received within 1 year of separation from service, thus the effective date cannot correspond to the day following separation from service. 38 C.F.R. § 3.400 (a)(2) . A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid or furnished to any individual under the laws administered by the Secretary. See 38 U.S.C.A. § 5101(a); 38 C.F.R. § 3.151(a). A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). A claim by a Veteran for compensation may be considered to be a claim for pension, and vice versa. 38 C.F.R. § 3.151(a). But VA is not automatically required to treat every pension claim as also being a compensation claim. Rather, the Secretary has to exercise his discretion under the regulation in accordance with the contents of the application and the evidence in support of it. See Stewart v. Brown, 10 Vet. App. 15, 18 (1997) (no evidence of intent to claim service connection within Veteran's non-service-connected pension claim); see also Willis v. Brown, 6 Vet. App. 433, 435 (1994) (the operative word "may" in the regulation, clearly indicates discretion). Thus, before the RO can adjudicate a claim for benefits, the claimant must submit a written document identifying the benefit and expressing some intent to seek it. Effective Date for Service Connection for Right Shoulder The Veteran filed a claim for service connection to include right shoulder disorder which he signed and dated November 17, 2010. This claim was received by the RO on November 22, 2010, according to the date stamp. There is no communication submitted prior to November 22, 2010, that could be reasonably construed as an application to claim entitlement to service connection for a right shoulder disorder. While he did submit VA Form 21-526 (Application for Compensation and/or Pension) on February 4, 2010, this form only listed the claimed disability to be his ogligodendroglioma (brain cancer). No intent to file for service connection for a right shoulder disorder was made in this document. Likewise, VA Forms 21-4138 (Statements in Support of Claim) submitted in March 2010, April 2010 and June 2010 all addressed his claim for brain cancer and Agent Orange exposure, with no mention of any intent to file a claim for a right shoulder disorder. Additional documents submitted in September 2010, to include another lay statement and a Substantive Appeal made no reference to a right shoulder disorder. The Veteran's representative likewise forwarded no documents to the RO that could be reasonably construed as a claim for service connection for a right shoulder disorder prior to November 22, 2010. Based on the above, the earliest date of receipt of an original claim of service connection for a right shoulder disorder is November 22, 2010, the date the RO received the Veteran's request for compensation for a right shoulder disorder. In reaching this decision, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not for application in this case because the preponderance of the evidence is against the assignment of an earlier effective date. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). Effective Date for Service Connection for Hearing Loss and Tinnitus The Veteran filed a claim for service connection, to include hearing loss and tinnitus which was received by the RO on November 30, 2010, according to the date stamp. This is the earliest date this claim was filed. Because the hearing loss and tinnitus claim were filed together at the same time, the Board shall discuss these separately claimed disorders together for effective date purposes. The Board notes that the appealed January 2011 rating affixed an effective date of November 30, 2010 for service connection for these disorders, and the August 2011 statement of the case addressing this matter appears to have erroneously used the November 22, 2010 effective date established for a grant of service connection for the right shoulder disorder as the effective date for the hearing loss and tinnitus. However as noted above and discussed further below, the correct effective date is shown to be the November 30, 2010 date for the grant of service connection for hearing loss and tinnitus. There is no communication submitted prior to November 30, 2010, that could be reasonably construed as an application to claim entitlement to service connection for either hearing loss or tinnitus. While he did submit VA Form 21-526 (Application for Compensation and/or Pension) on February 4, 2010, this form only listed the claimed disability to be his ogligodendroglioma (brain cancer). No intent to file for service connection for either hearing loss or tinnitus was made in this document. Likewise, VA Forms 21-4138 (Statements in Support of Claim) submitted in March 2010, April 2010 and June 2010 all addressed his claim for brain cancer and Agent Orange exposure, with no mention of any intent to file a claim for hearing loss or tinnitus. Additional documents submitted in September 2010, to include another lay statement and a Substantive Appeal made no reference to either hearing loss or tinnitus. The Veteran's representative likewise forwarded no documents to the RO that could be reasonably construed as a claim for service connection for hearing loss or tinnitus prior to November 30, 2010. Further, the original claim of service connection for a right shoulder disorder received on November 22, 2010, is noted to have also alleged entitlement to service connection for a urinary tract condition and for high blood pressure, but did not include any reference to hearing loss or tinnitus. Based on the above, the earliest date of receipt of an original claim of service connection for either hearing loss or tinnitus is November 30, 2010, the date the RO received the Veteran's request for compensation for hearing loss and tinnitus. In reaching this decision, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not for application in this case because the preponderance of the evidence is against the assignment of an earlier effective date. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for a urinary tract disorder is denied. Entitlement to service connection for hypertension is denied. An increased initial rating for right shoulder DJD, currently rated as 10 percent disabling is denied. Entitlement to an initial compensable disability rating for bilateral hearing loss is denied. Entitlement to an effective date earlier than November 22, 2010, for a grant of service connection for a right shoulder disorder, is denied. Entitlement to an effective date earlier than November 30, 2010, for a grant of service connection for hearing loss, is denied. Entitlement to an effective date earlier than November 30, 2010, for a grant of service connection for tinnitus, is denied. REMAND The Board finds that it is necessary to remand the issue of entitlement to service connection for brain cancer to address due process and developmental deficiencies. In regards to the brain cancer issue, the May 2010 VA examination conducted to address this issue is shown to be inadequate. The examiner, a physician's assistant indicated that the claims file was reviewed, but then later indicated that private or VA records were not reviewed. The examiner did report that service treatment records were reviewed, with no documentation of a brain tumor. The examiner also stated that the radiation oncologist's opinion was reviewed and there was no evidence of brain tumor or cancer on active duty. However the examiner failed to address the favorable opinion from the Veteran's radiation oncologist of January 2010, which stated that it is at least as likely as not the that Veteran's diagnosed grade III oligodendroglioma cancer with initial onset in November 2009 may be the result of exposure to Agent Orange defoliant spray, asbestos or lead while serving in the military. Instead the examiner stated that review of the medical literature was totally negative for any definitive cause of this particular cancer, therefore the Veteran's brain cancer is less likely than not caused by exposure to asbestos, Agent Orange or lead while on active duty. The examiner did not specify what medical literature was actually reviewed. The Board finds that another examination is necessary to adequately address the question of likely etiology of the Veteran's brain cancer, to include taking into consideration the opinion of the Veteran's radiation oncologist, and which specifies the literature relied on if any, in forming the opinion. In regards to the claimed exposures to Agent Orange, asbestos and lead, the Board notes that the Veteran's military occupational specialty (MOS) was BT-000 with his education including that of fireman, engineman and boiler technician. His lay statement in September 2010 alleged exposure to asbestos and lead paint in the boiler room, with the paint usually applied with a roller, although it was sometimes sprayed. His lay history and duties are consistent with exposure to asbestos and lead. Regarding the Veteran's claimed exposure to Agent Orange, his service treatment records and service personnel records reflect that he served aboard the U.S.S. Horne from September 1969 to February 1973, and was aboard the U.S.S. Samuel Gompers in February 1973 at the time he was discharged from service. He was also briefly transferred to the U.S.S. America while being treated for an infectious condition diagnosed as tonsillitis in May 1970. The consultation sheet shows that the request for the transfer to the U.S.S. America is May 30, 1970, during which time such ship was operating in the Gulf of Tonkin. See U.S.S. America CV 66 History, http: www.uscarriers.net/cv66history.htm. The Veteran is not shown to have been aboard the U.S.S. Samuel Gompers during a time it was shown to have had multiple dockings to piers at Danang, Vietnam in April 1972, and the U.S.S. Horne and U.S.S. America ships are neither shown to have gone ashore nor were on inland waters in Vietnam, but are shown to be "Blue Water" ships. See VA memorandum titled "Navy and Coast Guard Ships Associated with Service in Vietnam and Exposure to Herbicide Agents." (From Compensation Service Intranet Home Page: Rating Job Aids--Vietnam Era Navy Ship Agent Orange Exposure Development Site). The Veteran alleged that while aboard the U.S.S. Horne, he was about 15 miles from shore. He indicated that the windows were open for fresh air, and believed that Agent Orange exposure could have taken place from breathing this air. A lay statement from a fellow service member alleged that laundry was washed in ocean water believed to be contaminated with Agent Orange. The Veteran indicated that he came home on emergency leave, wherein he left the Horne by helicopter to the U.S.S. America and from there was flown via a mail plane to the airport in Danang, Vietnam and then went home via a cargo plane. He thought this took place in 1972 in a March 2010 statement, although this was during a time of treatment for brain cancer and he indicated having problems giving specifics. Although there is no official documentation to confirm that the Veteran went ashore in Vietnam, for emergency leave purposes or for any other reason, JSRRC did confirm that both ships were in the Gulf of Tonkin at the same time in December 1972, and confirmed that there were many helicopter launches and landings from ship to ship without official itineraries, and that only names of senior officers were recorded for such trips. Among such trips was one dated December 23, 1972 from the U.S.S. Horne to the U.S.S. America during such time both ships were in the Gulf of Tonkin. No passengers were listed and the official records did not document further transit or docking inland into Vietnam. However, such documentation of helicopter landings from ship to ship does support the Veteran's lay history of such transit to an airport in Vietnam via the U.S.S. America for emergency leave. The Board shall afford reasonable doubt in this instance and find that it is as likely as not that the Veteran entered Vietnam briefly while on transit for emergency leave for the purposes of presuming exposure to Agent Orange. Thus the examination to address the question of likely etiology of the Veteran's brain cancer, should also address whether it is as likely as not that such cancer was directly related to such exposure. While the oligodendroglia (brain cancer) has not been recognized as a condition presumptively associated with exposure to herbicides in service listed as listed under 38 C.F.R. § 3.309(e) nevertheless a claimant may establish service connection based on exposure to Agent Orange with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Brock v. Brown, 10 Vet. App. 155 (1997). Thereafter, the RO should attempt to obtain any additional evidence for which the claimant provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159 (2012). Accordingly, the case is REMANDED for the following action: 1. The claims file should be forwarded for review by an appropriate specialist(s) in oncology, to determine the nature and etiology of the Veteran's oligodendroglia, also claimed as cancer condition (brain cancer). The specialist should determine whether the Veteran's brain cancer was likely due to or aggravated by service. The claims file (to include the electronic record) and a separate copy of this remand must be made available to and reviewed by the examiner prior and pursuant to obtaining a medical opinion and the examination report must be annotated in this regard. After a review of the claims file, it is requested that the examiner describe in detail as follows: Whether the Veteran's brain cancer at least as likely as not (i.e., at least a 50/50 probability) was caused or aggravated by service, to include due to exposure to asbestos and lead while performing his duties as a fireman/boiler technician and/or exposure to Agent Orange, which has been conceded by the VA in this matter. In addressing the matter of the likely etiology of the brain cancer, the examiner must also address the service treatment records, service personnel records, lay evidence from the Veteran regarding his duties and exposure. The January 2010 favorable opinion from the Veteran's radiation oncologist must also be addressed. The examiner must provide a comprehensive report including complete rationale for all conclusions reached. 2. Following completion of the above development, the RO should readjudicate the claims on appeal. If the benefits sought on appeal remain denied, the appellant should be provided a supplemental statement of the case, which reflects consideration of all additional evidence received and all applicable regulations. It must contain notice of all relevant actions taken on the claim for benefits, to include a summary of the evidence and discussion of all pertinent regulations. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. No action by the appellant is required until she receives further notice. The appellant has the right to submit additional evidence and argument on the matter or matters 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs