Citation Nr: 1309211 Decision Date: 03/19/13 Archive Date: 04/01/13 DOCKET NO. 09-32 164A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a disability manifested by tingling/numbness in the extremities, difficulty walking on uneven ground/feeling ground under feet, decreased sensation to touch in extremities, decreased sensation to temperature, muscle weakness, fatigue or hand tremors, to include as secondary to a service-connected disability. 2. Entitlement to service connection for a disability manifested by dysphagia and difficulty swallowing, facial paralysis, pain and tension along ear, eye, memory loss and jaw line, to include as secondary to a service-connected disability. 3. Entitlement to service connection for a disability manifested by numbness in the pubic area (claimed as loss of sexual interest/lack of sensation in pelvic area), to include as secondary to a service-connected disability. 4. Entitlement to service connection for Meniere's disease, to include as secondary to a service-connected disability. 5. Entitlement to service connection for tarlov cyst. 6. Entitlement to an initial evaluation in excess of 10 percent for the left elbow scar. 7. Entitlement to an effective date earlier than September 24, 2009 for the grant of service connection for the left elbow scar. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Keyvan, Associate Counsel INTRODUCTION The Veteran had active service from January 1996 to October 2003. This matter comes before the Board of Veteran's Appeals (Board) on appeal from the April 2009 and March 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg Florida. The April 2009 rating decision denied service connection for tarlov cyst, and the March 2011 rating decision denied service connection for the remainder of the disorders listed in the title page. The Veteran was afforded a Board videoconference hearing, held by the undersigned, in November 2012. A copy of the hearing transcript has been associated with the record. The Veteran filed a claim for service connection for swelling of the penis in November 2003, which was subsequently denied in the June 2004 rating decision. The Veteran did not submit a notice of disagreement (NOD) with this decision, and the decision became final. In general, rating decisions that are not timely appealed become final. See 38 U.S.C.A. § 38 U.S.C.A. § 7105(d)(3). In September 2009, the Veteran filed a claim for service connection for loss of sexual interest/lack of sensation in pelvic area. While this claim includes symptoms surrounding the Veteran's reproductive organ region, it focuses on the pelvic region as a whole and predominantly concentrates on a different array of symptoms altogether, which may be characteristic of a different disorder than the claim previously denied in the June 2004 rating decision. The Board also notes that the Veteran previously filed a claim for service connection for a disability manifested by muscle weakness, fatigue, numbness and tingling of legs, feet and face, as well as his claim for service connection for syringomyelia with sleep apnea, vocal card paralysis, dysphagia, muscle weakness, facial tingling, fatigue and tingling/numbness of all four extremities, both of which to include as secondary to a service connected disability. Both these claims were denied in the May 2008 rating decision. The Veteran did not submit a NOD with the denial of service connection for these claimed disorders, and the May 2008 rating decision became final. However, in September 2009, the Veteran filed a claim for service connection for a myriad of symptoms, to include tingling/numbness in the extremities, dysphagia and difficulty swallowing. While some of these symptoms are similar to symptoms previously discussed and adjudicated in the May 2008 rating decision, the majority of these symptoms are new and can therefore be characteristic of different disorders altogether. As such, the Board will adjudicate the matters of entitlement to service connection for numbness in the public area; entitlement to service connection for a disability manifested by tingling/numbness in the extremities, muscle weakness, fatigue or hand tremors; and entitlement to service connection for a disability manifested by dysphagia and difficulty swallowing, facial paralysis, pain and tension along ear, eye, memory loss and jaw line on a de novo basis. The issues of entitlement to service connection for Meniere's disease, to include as secondary to a service connected disability, as well as the issues of entitlement to an initial evaluation in excess of 10 percent for the left elbow scar, and an effective date earlier than September 24, 2009 for the grant of service connection for the left elbow to are addressed in the REMAND portion of the decision below and is REMANDED to the RO. FINDINGS OF FACT 1. The Veteran does not have a chronic disability manifested by tingling/numbness in the extremities, difficulty walking on uneven ground/feeling ground under feet, decreased sensation to touch in extremities, decreased sensation to temperature, muscle weakness, fatigue or hand tremors. 2. The Veteran does not have a chronic disability manifested by dysphasia and difficulty swallowing, facial paralysis, pain and tension along ear, eye, memory loss and jaw line. 3. The Veteran does not have a chronic disability manifested by numbness in pubic area, which was claimed as loss of sexual interest/lack of sensation in pelvic area. 4. A tarlov cyst did not have its clinical onset in service and is not otherwise related to active duty. CONCLUSIONS OF LAW 1. The Veteran does not have a disability manifested by tingling/numbness in extremities, difficulty walking on uneven ground/feeling ground under feet, decreased sensation to touch in extremities, decreased sensation to temperature, muscle weakness, fatigue or hand tremors that is the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. The Veteran does not have a disability manifested by dysphagia and difficulty swallowing, facial paralysis, pain and tension along ear, eye, memory loss and jaw line that is the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 3. The Veteran does not have a disability manifested by numbness in the pubic area that is the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 4. A tarlov cyst was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist At the outset, the Board will address the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), enacted in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)(2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In this case, the Board finds that all notification and development action needed to arrive at a decision has been accomplished. In this respect, through a notice letters dated in July 2008, December 2009, and January 2010, the Veteran received notice of the information and evidence needed to substantiate his claims. Thereafter, he was afforded the opportunity to respond. Hence, the Board finds that the Veteran has been afforded ample opportunity to submit information and/or evidence needed to substantiate his claims. The Board finds that the above-referenced July 2008, December 2009 and January 2010 notice letters satisfy the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). In these letters, the RO also notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom he wanted the RO to obtain and consider evidence. 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. See Pelegrini v. Principi, 18 Vet. App. 112, 121 (2004). See also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (to be codified at 38 C.F.R. § 3.159) (removing the prior requirement that VA specifically ask the claimant to provide any pertinent evidence in his possession). These requirements were met by the aforementioned July 2008, December 2009 and January 2010 letters. In addition, the December 2009 and January 2010 letters informed the Veteran of evidence needed to establish secondary service connection. Further, the Veteran was provided notice regarding an award of an effective date and rating criteria in each letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 472 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Nothing about the evidence or any response to the RO's notification suggests that the case must be re-adjudicated ab initio to satisfy the notice requirements of the VCAA. There is no indication that any additional action is needed to comply with the duty to assist in connection with the claim on appeal. The Veteran's service treatment records as well as all identified and available private and VA treatment records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the service connection claims adjudicated herein. The duty to assist also includes obtaining a medical examination/opinion when such is necessary to make a decision on the claim, as defined by law. VA examinations with respect to the Veteran's claims for a disability manifested by tingling/numbness in the extremities, difficulty walking on uneven ground/feeling ground under feet, decreased sensation to touch in extremities, decreased sensation to temperature, muscle weakness, fatigue or hand tremors, as well as a disability manifested by dysphagia and difficulty swallowing, facial paralysis, pain and tension along ear, eye, memory loss and jaw line were conducted in April 2004, November 2007, December 2007, April 2008, and February 2011. A VA examination in connection to the Veteran's claim for service connection for tarlov cysts was conducted in April 2009. VA examinations in connection to the Veteran's claim for a disability manifested by numbness in the pubic area were conducted in April 2004 and February 2011. To that end, 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 and medical opinions obtained in this case are adequate, as they were predicated on a review of the Veteran's medical records, an interview of the Veteran and a discussion of his medical history. The medical opinions consider all of the pertinent evidence of record, to include statements given by the Veteran at the time of the VA examination, and provide a complete rationale for the opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the claims on appeal has been met. 38 C.F.R. § 3.159(c)(4). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome here, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Factual History The Veteran contends that he experiences a myriad of symptoms, to include numbness and tingling in his upper and lower extremities, muscle weakness, fatigue, and hand tremors; numbness in the pubic area; and dysphagia, difficulty swallowing, facial paralysis, memory loss and pain and tension along the ear; symptoms which either began in service, and/or are secondary to his service-connected post-traumatic headaches with Chiari I Malformation. At the November 2012 hearing, the Veteran testified that he began experiencing numbness and tingling in his lower extremities, as well as symptoms of dysphagia, difficulty swallowing and facial paralysis after his December 2001 motor vehicle accident (MVA) in service. According to the Veteran, he continued to seek treatment for these symptoms from January 2002 until his separation from active service. See November 2012 Hearing Transcript, (T.), pp. 5, 12-13. The Veteran asserts that the numbness in his pubic area arose six years prior, after his separation from service. See T., p. 4, 14. The Veteran also believes these symptoms are associated with his Chiari I Malformation, a disease he was diagnosed with in service. See T., pp. 7-9. Turning to the service treatment records, the Board notes that a June 1995 entry examination was negative for any neurological or gastrointestinal symptoms. The clinical evaluations of the Veteran's upper and lower extremities, as well as his genitourinary and neurologic system were shown to be normal, and the Veteran denied a history of neurological and gastrointestinal problems in his medical history report. In addition, the Veteran had a physical profile of 'P1','L1' and 'U1' at the time of this examination. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992) (observing that the 'PULHES' profile reflects the overall physical and psychiatric condition of the Veteran on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service)). In February 1996, the Veteran was seen at sick call with complaints of numbness in his right foot of one week duration. He was assessed with boot stress and scheduled for an x-ray, the findings of which were unremarkable. In March 1997, the Veteran underwent a circumcision procedure and post-operative records dated in April and August 1997 reflect that he was seen at the urology clinic with complaints of continued "puffiness on one side," and "swelling and soreness." He subsequently underwent a bilateral vasectomy in April 1998 and follow-up clinical records dated a week later reflect that the Veteran presented with complaints of right-sided testicular discomfort that radiates into the right groin/abdomen region. Upon physical examination, the treatment provider observed mild tenderness to palpation in the right testicular region and assessed the Veteran with "small cord hematoma." The Veteran was advised to rest over the weekend, take 800 milligrams of Motrin, and avoid certain activities until he was feeling better. The remaining records are clear for any similar complaints. In May 1998, the Veteran presented at sick call with complaints of a small bump on his penis of two days duration. The treatment provider described the Veteran as asymptomatic and took a urine/urethral culture, the results of which were normal. In June 1998, the Veteran presented at the Naval Hospital and reported a two month history of numbness and a "cold feeling" in his left hand. While the physical evaluation of the left hand and wrist was negative for any abnormalities, the Veteran was assessed with overuse injury of the left wrist. The Veteran was seen again in August 1998 with complaints of a tingling sensation along the ulnar aspect of his hand that travels through the proximal arm and posterior neck up to the back of his head. An October 1998 clinical note demonstrates that the Veteran underwent an electromyography (EMG) of the left upper extremity in August 1998, the results of which revealed early left ulnar nerve entrapment at the elbow. The Veteran underwent a left ulnar nerve transfer procedure soon thereafter, and follow-up treatment records showed an improvement of the Veteran's symptoms. Follow-up physical therapy notes dated in March and April 1999 revealed a diagnosis of bilateral "ulnar nn. radiculopathy" and findings from the October 2000 EMG were described as consistent with left ulnar neuropathy with slowing below the elbow. The Veteran was involved in a motor vehicle accident in December 2001 and subsequently taken to the Palmetto Baptist Medical Center for evaluation and treatment of his injuries. Upon physical examination, the Veteran reported to have neck discomfort when conducting range of motion exercises. He also underwent x-rays of his chest and cervical spine, the findings of which were shown to be normal. Based on his evaluation of the Veteran, as well as his review of the diagnostic records, the physician assessed the Veteran with a musculoskeletal strain in the neck, a chest contusion, and paresthesia in both hands. Soon thereafter, the Veteran began presenting at the Physical Therapy Clinic at the Army Hospital with complaints of neck and lower back pain. The Veteran was also seen at the military clinic for complaints of numbness in his left arm and a tingling sensation that runs down the center of his back. In May 2002, the Veteran presented at the Eisenhower Army Medical Center and reported a history of severe parasthesia and weakness following his December 2001 accident. Subsequent clinical records dated in June 2002 and issued from the military neurosurgical clinic, reiterate the Veteran's complaints of ongoing headaches, neck pain and weakness and numbness in the limbs following the December 2001 accident. In August 2002, the Veteran was evaluated at the South Carolina Neurological Clinic wherein he reported to experience headaches and ongoing numbness in his limbs following his motor vehicle accident. Upon conducting a neurological evaluation of the Veteran, the physician, J.C., M.D., observed no "drift" of the outstretched upper extremities and noted that the Veteran showed excellent strength to specific muscle testing in the upper and lower extremities. Based on his evaluation of the Veteran, Dr. J.C. did not detect any signs of neurological impairment and assessed the Veteran with mild posttraumatic headaches, which were reportedly not unusual following accidents. Dr. J.C. did note that the Veteran's magnetic resonance imaging (MRI) scans showed "a questionable and very small Arnold Chiari defect," which he characterized as a congenital disk change with no evidence of a symptomatic problem. At the June 2002 medical examination, the clinical evaluation of the upper extremities, feet, spine and neurologic system was shown to be abnormal. In the adjoining medical history report, the Veteran reported a history of numerous ailments, to include a history of numbness and tingling in the extremities, foot trouble, swollen or painful joints, frequent indigestion or heartburn, stomach, liver, intestinal trouble or ulcer, dizziness or fainting spells, frequent or severe headaches, paralysis, a period of unconsciousness or concussion, and meningitis, encephalitis, or other neurological problems. In the comments section, the Veteran described some of these problems in detail, and noted that he suffered from chronic headaches, stomach pain, difficulty swallowing, and chronic neck pain, as well as numbness/paralysis in all four limbs and back, and dizziness after participating in strenuous physical training exercise. In July 2002, a physician directed medical board was convened to determine whether the Veteran should be recommended for limited duty due to his inability to carry out the duties of his rank due to his medical condition - namely his chronic headaches. During the evaluation, the Veteran provided his medical history and reported a history of posterior neck pain which traveled down his spine since the December 2001 whiplash injury. The Veteran also reported symptoms of weakness in his lower extremities. While results from the physical and neurological evaluations were "essentially unremarkable by objective criteria," the examiner noted that the Veteran was undergoing further studies at the Neurosurgery division at the VA Hospital in Augusta, Georgia, and determined that the Veteran's medical condition precluded continuing with full-duty status. While the Veteran complained of symptoms of dysphagia following the December 2001 accident, clinical records dated prior to this in-service incident reflect that the Veteran received occasional medical treatment for gastrointestinal symptoms. Indeed, an August 1998 treatment report from the Naval Hospital reflects an assessment of gastritis, and results from an October 2001 upper gastrointestinal series revealed signs of significant reflux in the upper esophagus. A November 2001 clinical note reflects that the Veteran was assessed with possible gastroesophageal reflux disease (GERD). He underwent an esophageal dilation procedure in August 2002 and had a post-operative diagnosis of dysphagia at discharge. He subsequently underwent an esophagogastroduodenoscopy (EGD) in January 2003 and was discharged with a diagnosis of esophagitis. Treatment records dated in June 2003 and October 2003 reflect that the Veteran presented with ongoing complaints of difficulty swallowing. A February 2003 treatment report from the Neurology Clinic at the National Naval Medical Center (NNMC) in Bethesda reflects the Veteran's reports of daily headaches, dysphagia with solids, occasional numbness/tingling in the extremities and generalized weakness in the upper extremities since his MVA. Upon physical examination, the Veteran's motor strength in the upper and lower extremities was 5/5 bilaterally, and his sensation to pinprick, temperature and vibration was intact in all four extremities. The Veteran was evaluated at the NNMC in Bethesda again in February 2003, at which time, he reported to experience chronic daily headaches that worsen with exercise and position change, transient acral paresthesias, intermittent numbness over the neck and upper back, and one episode of unexplained syncope after exercise. The Veteran also reported significant daytime sleepiness, and denied signs of insomnia, memory loss or concentration difficulties. While the general and neurological examination findings were shown to be normal, the physician did observe mild decreased pin prick in circumferential pattern in the right lower extremity. However, the Veteran's reflexes to vibration, light touch and proprioception were shown to be intact. The Veteran also underwent an MRI of the cervical spine which revealed a posterior disk osteophyte complex around the C3 region. The remainder of the cervical spine was described as unremarkable with no signs of a syrinx, and the physician noted that the Veteran had upper and lower extremity somatosensory evoked potentials which were normal. Based on his evaluation of the Veteran, the physician diagnosed him with post traumatic headaches which did not exist prior to enlistment, and asymptomatic Arnold-Chiari I Malformation. He determined that the Veteran was unfit for full duty due to his daily headaches and nonspecific transient poorly localizing sensory symptoms, and referred him to the Physical Evaluation Board for fitness for duty determination. Physical Evaluation Board Proceedings were conducted in May 2003, and based on the medical findings, the Veteran was deemed unfit for duty due to his diagnoses of post traumatic headaches and asymptomatic Arnold-Chiari I Malformation. It was further recommended that the Veteran be separated from active duty. The Veteran presented at Columbia Neurological Associates in August 2003, at which time a thorough neurological evaluation was conducted, the results of which were negative for any abnormalities. The Veteran was shown to be alert and oriented to all fields and his short and long term memory was described as intact. Cranial nerves 1 through 12 were all described as either full, intact and/or strong, and it was specifically noted that cranial nerves 9 and 10 displayed good gag and swallow reflexes. The Veteran's motor strength was shown to be normal and 5/5 in all extremities, and coordination during finger-to-nose, heel-to-shin, and rapid alternating movement exercises was described as normal. In addition, findings from the sensory examination were described as normal. While it was noted that the physician, F.P., M.D., had detected what appeared to be signs of a tethered lumbar cord when reviewing an MRI scan of the lumbar spine, these MRI results were subsequently reviewed by J.F., M.D., a neurologist at the Eisenhower Army Medical Center, who ultimately found no clinical evidence of tethered cord syndrome. The remaining treatment records associated with the Veteran's period of service reflect frequent visits at various neurological treatment facilities, and continued complaints of numbness and tingling in the upper and lower extremities. At the October 2003 examination conducted pursuant to the Veteran's separation from service, the clinical evaluations of the genitalia, feet and spine were shown to be normal, while evaluations of the upper extremities, feet and spine were marked as abnormal. In addition, the Veteran reported a history of numerous health problems, to include recurrent back pain; numbness or tingling; foot trouble; frequent indigestion or heartburn; stomach, liver, intestinal trouble, or ulcer; dizziness or fainting spells; paralysis; a period of unconsciousness or concussion; meningitis, encephalitis, or other neurologic problems; and heart trouble. The post-service treatment records reflect that the Veteran was afforded a genitourinary and gall bladder examination in April 2004, at which time, it was noted that he had been diagnosed with GERD and treated for the H-pylori infection in service. The Veteran provided his medical history and described how food often gets stuck in his mid-epigastrium and mid-esophagus region. The Veteran also reported to have occasional swelling in his penis. According to the Veteran, he had a circumcision in 1996 which resulted in a bad infection secondary to that surgery, as well as a vasectomy in 1998 which resulted in pain in the left testicular region. Upon conducting a neurological evaluation of the Veteran, the examiner noted that the Veteran's sensation was intact to touch and that his motor strength and reflexes in the upper and lower extremities was 5/5 bilaterally and 2+ bilaterally, respectively. Physical examination of the genitalia revealed a normal circumcised penis, with signs of swelling "proximal to [the Veteran's] glans at the level of his circumcision." The testicles were described as normal and bilaterally descended to a normal position, the left testicle was described as non-elevated, and the Veteran's spermatic cord and epididymis were shown to be normal. Based on his evaluation of the Veteran, the examiner diagnosed the Veteran GERD and swelling of the penis, but noted that this was not debilitating to the point where it created medical complications, or prevented the Veteran from conducting certain activities. He also diagnosed the Veteran with left testicular pain secondary to his vasectomy procedure. In the June 2004 rating decision, the RO granted service connection for the Veteran's cervical disc disease with headaches secondary to MVA whiplash injury; right and left ulnar entrapment; GERD; traumatic cataract of the left eye; left knee patellar tendinitis and his hypertension. In August 2004, the Veteran presented at Columbia Neurological Associates with complaints of daily headaches. The objective medical findings were clear for any neurological abnormalities, and Dr. F.P., assessed the Veteran with chronic headaches and multiple neuralgias. In the December 2004 rating decision, the Veteran was granted a separate compensable evaluation for his post-traumatic headaches secondary to MVA. The RO also granted service connection for the Veteran's hyperextension of lower esophageal sphincter and combined this disability with the Veteran's previously service-connected GERD. VA treatment records dated from November 2004 to July 2007 demonstrate that the Veteran continued to visit with neurologists regarding his headaches as well as reported symptoms of numbness and tingling in the extremities. Other than an ongoing assessment of, and treatment provided for, chronic headaches, the objective evidence was clear for any neurological abnormalities. The Veteran underwent an MRI scan of the brain and cervical spine in August 2006, the impression of which revealed Type I Arnold Chiari malformation, but was otherwise essentially negative. A tarlov cyst was also identified at the right C5-6 intervertebral nerve root canal, but the treatment provider noted that this was not clinically significant. A March 2007 VA neurology note reflects the Veteran's complaints of numbness in his arms. The VA physician commented that report of the cervical spine MRI failed to reveal a reason for the Veteran's reported numbness, and results from the nerve conduction tests were shown to be normal. According to the VA physician, the Veteran's reported symptoms were most likely related to proximal muscle spasm. The Veteran was afforded a VA examination in connection to service-connected GERD in November 2007, at which time, he related his gastroesophageal symptoms to his Arnold-Chiari malformation. The Veteran reported to experience symptoms of dyspepsia as well as complaints of dysphagia with meat and bread. According to the Veteran, he has regurgitation or water brash on a daily basis. He also reported to have undergone several EGDs and three esophageal dilation procedures. Upon reviewing the Veteran treatment records, the VA examiner noted that the Veteran had undergone an EGD at the Dorn VA Medical Center (VACM) in Columbia, South Carolina in November 2004, and the findings discovered were clear for any significant abnormalities. The VA examiner acknowledged the Veteran's frequent gastroesophageal reflux symptoms, as well as his complaints of dysphagia, but noted that the EGD results did not reveal any significant abnormality of the esophagus. The examiner did note that the Veteran had a hypertensive lower esophageal sphincter. However, after reviewing the Veteran's claims file and additional literature with regard to symptoms associated with Arnold-Chiari malformation, the examiner determined that the Veteran has "simple gastroesophageal reflux." The Veteran was afforded another neurological VA examination in December 2007, the results of which demonstrated "a normal mental status, cranial nerves, motor system, sensory system, and reflex examination." According to the VA examiner, the Veteran's Arnold-Chiari I malformation was the proximate cause of his headaches. The May 2008 VA examination in connection to the Veteran's cervical spine condition was also clear for any neurological abnormalities. Throughout the appeal, the Veteran has submitted numerous internet medical articles and clinical studies which discuss the nature of Chiari Type I malformations, as well as any symptoms associated with this disorder. Based on a reading of these articles, people with Chiari malformations experience a variety of symptoms, to include headaches, dysphagia, pain, weakness, numbness, syncope, and visual disturbances. In February 2008, the Veteran filed a claim for service connection for syringomyelia, and asserted that the myriad of symptoms he had been experiencing were attributed to this diagnosis. The Veteran further maintained that his syringomyelia was secondary to his Arnold Chiari Type I malformation. The Veteran was afforded another VA examination in connection to his neurological symptoms in April 2008. The same VA examiner who conducted the December 2007 VA examination reviewed the Veteran's claims file and medical history, and noted that the Veteran had an ongoing diagnosis of Arnold-Chiari type I malformation, as reflected by multiple MRI studies. However, according to the VA examiner, no MRI report disclosed the presence of syringomyelia associated with the Arnold-Chiari malformation. Based on his review of the claims folder, to include previous examination reports, MRIs, and neurological findings, the VA examiner detected no signs of syringomyelia related to the Veteran's Arnold-Chiari malformation. However, the VA examiner determined that the Veteran's headaches "are at least as likely as not caused by or the result of [the Veteran's] Arnold-Chiari malformation aggravated by a motor vehicle accident." In the August 2009 rating action, the Decision Review Officer (DRO) granted service connection for the Veteran's Chiari Malformation and combined it with his previously service-connected post traumatic headaches. In January 2011, the Veteran presented at the Dorn VAMC for follow-up care for his chronic daily headaches. The Veteran was alert and oriented on physical examination, and his cranial nerves were described as normal. The VA physician observed "no drift" in the outstretched arms, and characterized the Veteran's reflexes as symmetric and his strength testing as normal. The VA physician acknowledged the Veteran's history of Chiari malformation, but noted that diagnosis was mild in nature. She (the VA physician) also prescribed him with new medication "for [his] migraines." The Veteran was afforded a VA brain and spinal cord examination in February 2011, at which time the VA examiner reviewed the Veteran's medical history and interviewed him regarding his military experiences; namely the December 2001 MVA. The VA examiner acknowledged the Veteran's complaints of tingling sensations in the left side of his face, as well as the upper and lower extremities. Examination of the cranial nerves demonstrated no muscle atrophy and there were no noted disturbances in the Veteran's ocular motility. Examination of the motor system demonstrated a normal muscle mass, tone, strength, station, gait and coordination, and primary sensation testing in the upper extremities revealed no abnormalities. In particular, the VA examiner observed no abnormality in the left ulnar nerve distribution where the Veteran underwent the ulnar nerve transposition. The examiner further described the tendon reflexes as intact, and found no signs of pathologic reflexes. Based on his evaluation of the Veteran, the VA examiner observed a "subjective response of an abnormality in the left trigeminal sensory nerve distribution," but observed no trigeminal motor disturbance. While he noted "a nonanatomical distribution of impaired monofilament light touch in both lower extremities," the examiner determined there to be no abnormality that can be clearly related to this Arnold Chiari malformation. The examiner further observed no psychiatric manifestations or visual field disturbances, nor any abnormalities in the joints or impairment in the Veteran's bowel or bladder function. The examiner also noted that the Veteran's sense of smell was tested with aromatic oils and correctly identified. According to the VA examiner, the Veteran's Arnold Chiari malformation was asymptomatic and not related to any of his current symptoms. The Veteran was afforded a VA genitourinary examination in February 2011, at which time he denied any problems with his sexual drive. According to the Veteran, while he had some remote swelling after his in-service circumcision, he did not experience any further problems. The Veteran also denied any renal dysfunction, incontinence or erectile dysfunction and added that he does not have a genitourinary disorder which affects his job or his activities of daily living. The Veteran further denied any testicular issues at that time. According to the VA examiner, there was no subjective evidence of decreased sexual desire or penile swelling. A nerve conduction study was conducted in April 2011, the findings of which showed that the left ulnar sensory response is "low amplitude" and the left ulnar motor conduction velocity revealed "significant slowing in the segment that is transposed anterior to the left medial epicondyle." It was noted that the remainder of the nerve conduction velocity tests of the upper and lower extremities fell within normal limits. II. Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also 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). In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, 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. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). B. Issues One, Two and Three Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. Secondary service connection is also available for chronic aggravation of a nonservice-connected disorder. In reaching the determination as to aggravation of a nonservice-connected disability, the baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. These findings as to baseline and current levels of severity are to be based upon application of the corresponding criteria under the Schedule for Rating Disabilities (38 C.F.R. part 4) for evaluating that particular nonservice- connected disorder. 38 C.F.R. § 3.310. The evidence clearly shows the Veteran's complaints of numbness and tingling in the extremities, muscle weakness, fatigue, dysphagia and difficulty swallowing during his period of service. However, with the exception of the Veteran's post-traumatic headaches with Chiari I Malformation, degenerative disc disease in the cervical spine, right and left ulnar neuropathy, and GERD (disabilities which have already been granted service connection), the weight of the evidence demonstrates that during the Veteran's service there were no combination of manifestations sufficient to identify a disability or disabilities for the associated symptoms so as to establish chronicity of such claimed disorders during service. 38 C.F.R. § 3.303(b). While the service treatment records reflect a myriad of neurological and gastrointestinal symptoms; there was no actual clinical finding of a chronic disability or disabilities associated with these specific symptoms beyond those disabilities for which service connection has already been granted. Thus, while the Veteran experienced episodes of numbness and tingling in the right and lower extremities, as well as muscle weakness, and periods of dysphagia and difficulty swallowing while on active duty service, the service treatment records do not reflect any other chronic disability or disabilities associated with these particular symptoms which have not already been identified and diagnosed. Upon consideration of the above evidence, the Board finds that the preponderance of the evidence is against the Veteran's claims of service connection for a disability manifested by tingling/numbness in the extremities, difficulty walking on uneven ground/feeling ground under feet, decreased sensation to touch in extremities, decreased sensation to temperature, muscle weakness, fatigue or hand tremors; a disability manifested by dysphagia and difficulty swallowing, facial paralysis, pain and tension along ear, eye, memory loss and jaw line; and a disability manifested by numbness in the pubic area. With regard to these claims, the Board notes that the existence of an underlying disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that 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). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Here, the greater weight of the evidence points to the Veteran not having any diagnosed neurological, gastrointestinal or visual pathology beyond those disabilities which have already been diagnosed and for which service connection has already been granted. With respect to the Veteran's claim for a disability manifested by tingling/numbness in the extremities, difficulty walking on uneven ground, decreased sensation to touch in extremities, decreased sensation to temperature, muscle weakness, fatigue and hand tremors, the Board notes that other than the diagnoses of post-traumatic headaches and the Arnold-Chiari I Malformation, none of the private/VA treatment providers, and VA examiners have identified a current disability or disabilities associated with these symptoms. Indeed, a review of the entire medical evidence of record is completely absent for a diagnosis pertaining to these specified symptoms. As discussed above, numerous neurological tests have been conducted throughout the pendency of the appeal, and with the exception of some identified impairment in the upper extremities, the objective medical evidence has consistently been clear for any other cognitive or peripheral neurological disability. The Board acknowledges the August 2004 treatment report from Columbia Neurological Associates, wherein Dr. F.P. assessed the Veteran with multiple neuralgias. Despite this assessment, the objective evidence was clear for any neurological impairment or abnormalities. The Board is more persuaded by the evaluations which concluded there to be no neurological abnormalities because of the more thorough approach taken during these evaluations. In this regard, the Board acknowledges the February 2011 VA examination report which noted that the Veteran responded to an abnormality in the left trigeminal sensory nerve distribution. However, this was based on the Veteran's subjective reaction and not on objective testing. Indeed, objective testing was clear for any abnormalities in the left trigeminal sensory nerve distribution. With respect to the Veteran's claim for a disability manifested by dysphagia and difficulty swallowing, facial paralysis, pain and tension along ear, eye, memory loss and jaw line, the Board again notes that, other than the diagnoses of GERD with hyperextension of lower esophageal sphincter, none of the private/VA treatment providers, and VA examiners have identified a current disability or disabilities associated with these symptoms. Testing has consistently shown the Veteran's short and long-term memory to be intact. While the Veteran has repeatedly described symptoms of dysphagia and difficulty swallowing, multiple EGD findings were clear for any significant abnormalities. While the service treatment records reflected varying diagnoses of esophagitis and gastritis, the post-service medical evidence of record, namely, the April 2004 and December 2007 VA examination reports reflected a singular diagnosis of GERD - a disability for which service connection has already been granted. Moreover, as previously discussed above, the Veteran underwent a thorough neurological evaluation at Columbia Neurological Associates in August 2003, and upon evaluating the cranial nerves, Dr. F.P. noted that cranial nerves 9 and 10 displayed good gag and swallow reflexes. Tellingly, while the Veteran has claimed to have a disability manifested by symptoms of pain and tension along the ears and eyes, his VA examination reports have been clear for similar types of complaints. While the Veteran did undergo an electronystagmography (ENG) in October 2010, and the results revealed abnormal saccadic and optokinetic tests, these findings appear to be related to the Veteran's meniere's disease, and will be discussed in greater detail in the Remand section below. Also, with respect to the Veteran's claimed symptoms of facial paralysis, objective testing of the cranial nerves was always devoid of any abnormalities, and while the Veteran exhibited a subjective response of an abnormality in the left trigeminal sensory nerve, objective testing identified no abnormalities in the trigeminal sensory nerve distribution. See April 2004, December 2007 and February 2011 VA examination reports. Again, any additional symptoms of facial paralysis may be due to the Veteran's meniere's disease. Importantly, the February 2011 VA examiners also did not identify a separate disability or disabilities in connection to the above-reference symptoms. As such, the evidence does not show that the Veteran currently has the disability for which benefits are being claimed. With respect to the Veteran's claim for a disability manifested by numbness in the pubic area, the Board again points to the medical evidence outlined above, and notes that none of the private/VA treatment providers, and VA examiners have identified a current disability or disabilities associated with these symptoms. Indeed, a review of the entire medical evidence of record is completely absent for a diagnosis pertaining to these specified symptoms. While the April 2004 VA examiner assessed the Veteran with swelling of penis and left testicular pain secondary to testicular procedure, he did not find any intrinsic pathology associated with the Veteran's reproductive organs. As previously noted above, the assessment of a pain does not equate to underlying disease. In other words, pain itself is not a disease. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). With respect to the Veteran's complaints of numbness in the pubic region, neurological evaluations and MRI reports have consistently been negative for any noted impairment. Moreover, the Veteran denied any genitourinary disorders or problems associated with his reproductive organs at the February 2011 VA examination, and the VA examiner did not identify any intrinsic pathology in the pubic region. The Board notes further that although the Veteran has complained of these symptoms in multiple statements to VA and during his hearings, the greater weight of the evidence is that he does not have any pathology associated with these symptoms. The Board has considered the Veteran's assertions that these symptoms are associated with neurological or gastrointestinal pathology that is/are related to his time in service and/or secondary to a service-connected disability. However, as a layperson, the Veteran is not competent to give a medical opinion on the diagnosis of a claimed disorder. He is competent to report on symptoms he experienced either during or following service, but not to say what any diagnosis is. Thus, while the Veteran is competent to report symptoms observable to a layperson, such as numbness and tingling in the lower extremities and pubic region and difficulty swallowing, a diagnosis that is later confirmed by clinical findings, or a contemporary diagnosis, he is not competent to independently provide a medical diagnosis or opine as to the specific etiology of a condition. See Davidson v. Shinseki, 581 F.3d 1313 (2009). Further, the April 2004, November 2007, December 2007, May 2008 and February 2011 VA examiners considered the Veteran's report of in-service and post-service symptoms in reaching their medical conclusions. Consequently, in this case, lay assertions of medical diagnosis or etiology cannot constitute evidence upon which to grant a claim for service connection. Lathan v. Brown, 7 Vet. App. 359, 365 (1995). The Board notes that secondary service connection requires (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). However, the fact remains that the objective medical evidence of record does not demonstrate that the Veteran currently suffers from any diagnosed disorder manifested by the claimed symptoms on appeal. As such, service connection for disabilities manifested by tingling/numbness in the extremities, difficulty walking on uneven ground/feeling ground under feet, decreased sensation to touch in extremities, decreased sensation to temperature, muscle weakness, fatigue or hand tremors; dysphagia and difficulty swallowing, facial paralysis, pain and tension along ear, eye, memory loss and jaw line; and numbness in the pubic area are not warranted on a secondary basis either. Because the medical evidence in the current appeal does not establish that the Veteran has any current pathology associated with the claimed symptoms on appeal, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for disabilities manifested by tingling/numbness in the extremities, difficulty walking on uneven ground/feeling ground under feet, decreased sensation to touch in extremities, decreased sensation to temperature, muscle weakness, fatigue or hand tremors; dysphagia and difficulty swallowing, facial paralysis, pain and tension along ear, eye, memory loss and jaw line; and numbness in the pubic area. The benefit-of-the-doubt provisions do not apply. Service connection for disabilities manifested by tingling/numbness in the extremities, difficulty walking on uneven ground/feeling ground under feet, decreased sensation to touch in extremities, decreased sensation to temperature, muscle weakness, fatigue or hand tremors; dysphagia and difficulty swallowing, facial paralysis, pain and tension along ear, eye, memory loss and jaw line; and numbness in the pubic area is not warranted. B. Tarlov Cysts The Veteran contends that his tarlov cyst had its onset in service. A review of the service treatment records is negative for any notations or findings of a tarlov cyst. A brief recitation of the factual evidence listed above reflects that the Veteran was involved in a motor vehicle accident in December 2001 and sustained whiplash injuries in the cervical spine region. He underwent an x-ray of the cervical spine in December 2001, the findings of which were shown to be normal. As previously noted above, the Veteran was evaluated at the NNMC in Bethesda in February 2003, and upon reviewing a MRI of the cervical spine, the physician noted that the x-ray findings revealed a posterior disk osteophyte complex around the C3 region. According to the physician, there was no cord signal abnormality at this level. The remainder of the diagnostic records associated with the Veteran's period of service is absent any radiological evidence of a tarlov cyst. While the Veteran marked to have a history of tumor, growth, cyst, or cancer on his October 2003 medical history report pursuant to his separation from service, in the comments section, he indicated that he had a cyst on the left side of his neck, and further appeared to be referring to his diagnosed Arnold-Chiari Malformation. While the diagnostic records do reflect findings of the Arnold-Chiari Malformation, the record is devoid of evidence identifying a cyst on the left side of the neck. Moreover, the record is absent any evidence identifying a tarlov cyst in the cervical spine during the Veteran's period of service. The post-service treatment records reflect that the Veteran underwent an MRI scan of the cervical spine in August 2006, the findings of which did reveal a "5 mm [millimeter] in diameter Tarlov cyst...at the right C5-6 intervertebral nerve root canal." According to the VA physician who made this discovery, this was not a clinically significant finding. The Veteran was afforded a VA examination in connection to this claimed disorder in April 2009. During the evaluation, the Veteran provided his medical history, and reported to have had trouble with his neck since his December 2001 in-service MVA. The Veteran described a throbbing pain in the posterior neck and bilateral arms and a constant tingling sensation that travels down the spine and medial aspects of both forearms and lower legs. Upon physical examination, the VA examiner noted that light touch sensation was diminished in the left ring and little fingers and the medial aspect of the left forearm up to the elbow. Upon reviewing the August 2006 MRI report, the examiner confirmed findings of a 5 mm Tarlov cyst at the right C5-6 intervertebral nerve root canal. Based on his review of the records and evaluation of the Veteran, the examiner diagnosed the Veteran with cervical 5 mm tarlov cyst, and previous left ulnar nerve transposition at the elbow. According to the VA examiner, it is less likely than not that the Veteran's right C5-C6 tarlov cyst is due to his in-service accident. The examiner explained that these cysts, particularly when they are this size, are usually considered to be incidental findings and are not predominantly caused by trauma such as the Veteran experienced. In considering all of the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for tarlov cyst. As previously discussed, the service treatment records are clear for any evidence showing that the tarlov cyst had its onset in service. While the Veteran reported a history of a cyst on his left neck at his October 2003 separation examination, he appears to be referring to an external growth on his body rather than something located within the spinal canal which can only be identified through medical imaging. Moreover, the diagnostic records, as described by the physicians who reviewed them in service, are absent any findings of a tarlov cyst. Additionally, the post service medical evidence shows that the Veteran was first diagnosed with tarlov cyst in August 2006, nearly three years after he was discharged from service. A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service). Additionally, the Veteran has not provided any competent evidence to demonstrate that the current tarlov cyst was caused by or a result of his period of service. In short, there is no competent evidence to support the claim. As noted above, the April 2009 VA examiner opined that there was no relationship between the Veteran's tarlov cyst and service. The Board finds the April 2009 VA examiner's opinion to be highly probative, as it is based on a discussion with the Veteran regarding his medical history and current condition, a complete review of the medical records, and a physical examination. The opinion is also consistent with the other evidence of record and is supported by a rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (which holds that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion.) Furthermore, the opinion was obtained from a licensed physician rather than a lay person. Thus, the Board finds that the April 2009 VA examiner's opinion is entitled to more probative weight than the Veteran's assertion that his tarlov cyst had its onset and/or is causally related to service. Without medical evidence of a nexus between a claimed disease or injury incurred in service and the present disease or injury, service connection cannot be granted on a direct basis. Hickson, 12 Vet. App. at 253. In reaching this determination, the Board has also considered the lay statements of record. Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997), Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991)("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, however, although the Veteran is competent to describe symptoms of pain and numbness in various areas of his body, he is not competent to comment on the etiology of such a disorder. While a layperson can provide evidence as to some questions of etiology or diagnosis, the question of a medical relationship between a cyst located in the spinal canal and service, which would require more than direct observation to resolve, is not in the category of questions that lend themselves to resolution by lay observation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), Barr v. Nicholson, 21 Vet. App. 303, 309 (2007), Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). Here, the Veteran is competent to report symptoms of pain and numbness in various areas of his body because such actions come to him through his senses and, as such, require only personal knowledge rather than medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Veteran is not competent to opine on the question of etiology and, therefore, his statements asserting a relationship between his tarlov cyst and service do not constitute competent medical evidence on which the Board can make a service connection determination. Significantly, the Board points to the service treatment records, namely the diagnostic records issued during the Veteran's period of service, which are absent any indication or identification of a tarlov cyst. Therefore, after considering all of the evidence of record, the Board finds that, as previously discussed, the evidence does not show that service connection for tarlov cyst is warranted. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against this claim. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a disability manifested by tingling/numbness in the extremities, difficulty walking on uneven ground/feeling ground under feet, decreased sensation to touch in extremities, decreased sensation to temperature, muscle weakness, fatigue or hand tremors is denied. Entitlement to service connection for a disability manifested by dysphagia and difficulty swallowing, facial paralysis, pain and tension along ear, eye, memory loss and jaw line is denied. Entitlement to service connection for a disability manifested by numbness in the pubic area is denied. Entitlement to service connection for tarlov cyst is denied. REMAND The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). A. Meniere's Disease During the November 2012 hearing, the Veteran testified that he began experiencing symptoms akin to Meniere's disease in service, specifically following the December 2001 motor vehicle accident in service. The Veteran also relates these symptoms to his service-connected post-traumatic headaches with Chiari I malformation. See November 2012 Hearing Transcript (T.) pp. 9-11, 13-14. Turning to the service treatment records, the Board notes that the clinical evaluation of the ears, nose and drums was shown to be normal at the June 1995 enlistment examination. In addition, the Veteran did not report a history of ear problems, dizziness or fainting spells in his medical history report. In December 2001, the Veteran sustained a whiplash injury in the cervical spine region after he was involved in a motor vehicle accident. Soon thereafter, he began visiting the military clinic and a number of other treatment facilities on a regular basis with complaints of a ongoing headaches, lightheadedness and pain in the neck region. In October 2002, the Veteran presented at the Army Medical Center with complaints of ongoing headaches, and he added that he had recently been experiencing episodes of loss of consciousness and double vision. During a January 2003 treatment visit at the Army Medical Center, the Veteran described his October 2002 syncopal episode, and explained that he had just finished a physical training exercise that afternoon when he suddenly experienced loss of consciousness for an unknown duration of time. He was assessed with a single episode of syncope of unclear etiology. At the March 2003 Medical Board Examination, the Veteran reported a history of dizziness or fainting spells, and periods of unconsciousness or concussion. He noted that these episodes tend to occur after participating in a strenuous physical training exercise. At the October 2003 separation examination, the Veteran again reported a history of dizziness and fainting spells which reportedly began occurring during basic training. The Veteran was afforded a VA examinations in connection to this claim in October 2010 and November 2010. Specifically, the Veteran underwent an ENG in October 2010, the impression of which revealed a reduced vestibular response in the left ear and abnormal saccadic and optokinetic tests. During the audiological evaluation, the Veteran reported no hearing loss, but did claim to experience very brief episodes of tinnitus which occur in his left ear approximately once or twice a day. The Veteran also explained that he began having episodes of true vertigo in 2002. According to the Veteran, he experiences two to three episodes of vertigo a day, and each episode lasts approximately 10 minutes at a time. The Veteran also reported occasional nausea and added that he experiences tinnitus and fullness in his left ear whenever he has these attacks. Based on her review of the ENG results and audiogram, the audiologist diagnosed the Veteran with probable early meniere's disease in the left ear. In an addendum, she determined that the Veteran appeared to have a peripheral vestibular disorder. Subsequent VA outpatient records dated in December 2010 reflect an ongoing impression of meniere's disease. As previously noted in the factual history section, the February 2011 VA examiner determined that the Veteran's Arnold Chiari malformation was asymptomatic and not related to any of his current symptoms. If VA undertakes the effort to provide the Veteran with a medical examination, it must ensure that such exam is an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As mentioned above, establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by, or (b) proximately aggravated by, a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In this case, the Board does not find the October and November 2010 examination reports in conjunction with the February 2011 VA medical opinion to be adequate. First, an opinion regarding whether the Veteran's meniere's disease had its onset in, and/or was causally/etiologically related to service has not been provided. Additionally, the record remains unclear as to whether the Veteran's service-connected post-traumatic headaches with Chiari I Malformation aggravated his current meniere's disease. As such, another remand is necessary for another VA examination and opinion. 38 C.F.R. § 3.159(c)(4)(i). B. Entitlement to an initial evaluation in excess of 10 percent for the left elbow scar, and an effective date earlier than September 24, 2009 for the grant of service connection for the left elbow scar. In the March 2011 rating decision, service connection was granted for the left elbow scar and evaluated as noncompensably disabling, effective November 24, 2010. In his March 2011 NOD the Veteran disagreed with both the disability rating and effective date assigned for the service-connected left elbow scar. A subsequent rating decision was issued in July 2011 increasing the disability rating for the service-connected left elbow scar to 10 percent, and changing the effective date assigned for the rating to September 24, 2009. The Board notes, with respect to increased ratings, the United States Court of Appeals for Veterans Claims (Court) has held that on a claim for an original or increased rating, the appellant will generally be presumed to be seeking the maximum benefit allowed by law or regulations, and it follows that such a claim remains in controversy where less than the maximum benefit is allowed. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Court further held that, where a claimant has filed a NOD as to a RO decision assigning a particular rating, a subsequent RO decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the appeal. Id. As the Veteran has not expressed satisfaction with this rating and an effective date earlier than September 24, 2009 is still possible, the claims for entitlement to an initial rating greater than 10 percent for the service-connected left elbow scar, and entitlement to earlier effective date remain before the Board on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). However, a Statement of the Case (SOC) has not been issued addressing this claim. The Court has held that, when an appellant files a timely NOD as to a particular issue and no SOC is furnished, the Board should remand, rather than refer, the claim for issuance of an SOC. See Manlicon v. West, 12 Vet. App. 238 (1999). Under these circumstances, an SOC concerning the issues of entitlement to an initial evaluation in excess of 10 percent for the left elbow scar, and an effective date earlier than September 24, 2009 for the grant of service connection for the left elbow scar, should be issued. However, these issues will be returned to the Board after issuance of the SOC only if perfected by the filing of a timely substantive appeal. See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997); Archbold v. Brown, 9 Vet. App. 124, 130 (1996). Accordingly, the case is REMANDED for the following action: 1. Issue to the Veteran a Veterans Claims Assistance Act of 2000 notice letter regarding the issue of entitlement to service connection for Meniere's disease, to include as secondary to a service-connected disability. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any Meniere's disease present. The claims folder and a copy of this remand and all records on Virtual VA must be made available to, and reviewed by, the examiner. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, and all pertinent pathology should be noted in the examination report. Consideration should be given to the Veteran's history and particularly to any statements regarding continuity of symptoms since service. [The examiner should specifically take into consideration these service treatment records: the October 2002 health record documenting one of the Veteran's loss of consciousness episodes; the January 2003 clinical note which assesses the Veteran with a single episode of syncope of unclear etiology; and the October 2003 separation examination report reflecting the Veteran's reported history of dizziness. The examiner should also take note of the October 2010 and November 2010 examination reports, which reflect the Veteran's complaints of tinnitus.] If Meniere's disease is present, the examiner should express an opinion as to whether it at least as likely as not, i.e., a 50 percent probability or greater, had its onset in service or is otherwise related to the Veteran's military service, to include his in-service syncopal episode and complaints of dizziness. In answering this question, the examiner should address the Veteran's assertions that he has experienced balance problems and symptoms of dizziness since service, and should set forth the medical reasons for accepting or rejecting the Veteran's statements regarding continuity of symptoms since military service. If the examiner finds that Meniere's disease is unlikely directly related to service, then the examiner should express an opinion as to whether it is at least as likely as not, i.e., a 50 percent probability or greater, that Meniere's disease was proximately due to his service-connected post-traumatic headaches with Chiari I Malformation. If aggravated, specify the baseline of Meniere's disease prior to aggravation, and the permanent, measurable increase in Meniere's disease resulting from the aggravation. A complete rationale should be provided for all opinions expressed. 3. Thereafter, furnish the Veteran an SOC regarding the issues of entitlement an initial evaluation in excess of 10 percent for the left elbow scar, as well as entitlement to an effective date earlier than September 24, 2009 for the grant of service connection for the left elbow scar. The Veteran should be informed that he must file a timely and adequate substantive appeal in order to perfect an appeal of these issues to the Board. See 38 C.F.R. §§ 20.200, 20.202, 20.302(b). Only if the Veteran perfects a timely appeal should these claims be certified to the Board. 4. After completing the above requested development, re-adjudicate the issue of entitlement to service connection for Meniere's disease, including as secondary to service-connected post-traumatic headaches with Chiari I Malformation. If the decision remains in any way adverse to the Veteran, he should be provided with a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ THOMAS. J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs