Citation Nr: 1320874 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 05-05 513 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to a rating in excess of 10 percent for right foot dorsal exostosis and resection of neuroma. 2. Entitlement to a compensable rating for left ear hearing loss. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and a mood disorder as secondary to a service-connected right foot disability. 4. Entitlement to service connection for a gastrointestinal (GI) disorder, to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from September 1993 to September 1997. This case comes before the Board of Veterans' Appeals (Board) on appeal from August 2004 and April 2009 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The August 2004 rating decision denied an increased rating for the right foot disability and service connection for a GI disability. The April 2009 rating decision denied service connection for a psychiatric disorder and continued a compensable rating for left ear hearing loss. In January 2007, the Board issued a decision remanding the issue of an increased rating for the right foot disability and denied entitlement to service connection for a GI disorder. The Veteran appealed the denial of the service connection claim to the Court of Appeals for Veterans Claims (Court). In a September 2009 memorandum decision, the Court vacated the Board's January 2007 denial of the claim for service connection for a GI disorder and remanded the issue. In September 2010, the Board issued another decision, remanding the issue of service connection for a GI disorder and denying an increased rating for a right foot disability. The Veteran appealed the denial of the increased rating claim to the Court, and in June 2011, the Court granted a Joint Motion for Remand filed by the parties, which requested that the portion of the September 2010 decision that denied an increased rating for the right foot disability be vacated and remanded. In November 2012, the Board remanded the claims for further development. The appeal has now returned to the Board for further action. FINDINGS OF FACT 1. The Veteran's right foot dorsal exostosis and resection of neuroma most nearly approximates mild to moderate incomplete paralysis of the posterior tibial without separate and distinct orthopedic impairment or arthritis. 2. The Veteran's right foot surgical scar is not the result of a burn injury and is nontender, nonpainful, stable, and does not encompass an area greater than 929 square centimeters (sq. cm.) or result in limitation of motion. 3. The Veteran's left ear manifests no more than Level I hearing loss. 4. The Veteran does not have PTSD. 5. An acquired psychiatric disorder other than PTSD is not etiologically related to active duty service or a service-connected disease or injury. 6. The Veteran served in the Southwest Asia theatre of operations and has a current GI disability manifested by abdominal cramps, vomiting, and diarrhea that has not been attributed to a known clinical diagnosis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for right foot dorsal exostosis and resection of neuroma have not been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 4.118, Diagnostic Codes7800-7805 (2003); 38 C.F.R. §§ 4.71a, 4.118, 4.124a, Diagnostic Codes 5003, 7800-7805, 5276-5284, 8725 (2012). 2. The criteria for a compensable rating for left ear hearing loss have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.383, 4.85, 4.86, Diagnostic Code 6100. 3. PTSD was not incurred or aggravated during active duty service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304(f). 4. An acquired psychiatric disorder other than PTSD was not incurred or aggravated during service and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 5. Service connection for a GI disorder manifested by abdominal pain, vomiting, and diarrhea as a qualifying chronic disability is warranted. 38 U.S.C.A. §§ 1110, 1117, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Rating Claims Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Right Foot Disability Service connection for status post excision of dorsal exostosis and resection of a neuroma of the right foot was granted in an October 1997 rating decision. An initial noncompensable evaluation was assigned effective September 7, 1997, under Diagnostic Code 5299-5279. In a November 1998 decision, the rating was increased to 10 percent, effective June 17, 1998. The August 2004 rating decision on appeal continued the current 10 percent evaluation. In a May 2008 rating decision that did not specifically address the evaluation of the right foot disability, the RO cited Diagnostic Code 5279-8725 in reference to rating this disability. The Veteran contends that an increased rating is warranted for his right foot condition as it is productive of constant severe pain that impacts his ability to walk, stand, and work. The Veteran's service-connected right foot disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5279-8725. Pursuant to 38 C.F.R. § 4.27, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. This hyphenated code may be read to indicate that anterior metatarsalagia is the service-connected disorder, and it is rated as if the residual condition is neuralgia of the posterior tibial nerve under Diagnostic Code 8725. Under Diagnostic Code 5279, a maximum 10 percent disability rating is warranted for metatarsalagia, anterior (Morton's disease), unilateral, or bilateral. 38 C.F.R. § 4.71a. Under Diagnostic Code 8725 (neuralgia), a 10 percent evaluation is afforded for mild or moderate incomplete paralysis of the posterior tibial nerve. Severe incomplete paralysis is evaluated as 20 percent disabling. Complete paralysis is evaluated as 30 percent disabling and involves paralysis of all muscles of the sole of the foot, frequently with painful paralysis of a causalgic nature, inability to flex toes, weakened adduction, and impaired plantar flexion. 38 C.F.R. § 4.124a. The October 1997 rating decision that awarded service connection for the Veteran's right foot disability originally evaluated the disability by analogy to Diagnostic Code 5279. In May 2008, a rating code sheet associated with a rating decision that did not specifically address the evaluation of the right foot disability indicated that the rating diagnostic code had been changed to Diagnostic Code 5279-8725 for neuralgia. The Board finds that a rating in excess of 10 percent under Diagnostic 8725 is not warranted. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. The introductory note to Diseases of the Peripheral Nerves defines the term "incomplete paralysis" as a degree of lost or impaired function substantially less than the type pictured for complete paralysis. It adds that when the involvement of a peripheral nerve is wholly sensory, the rating should be for the mild or, at most, moderate degree. 38 C.F.R. § 4.124a. After review of the competent lay and medical evidence, the Board finds that the Veteran's right foot neurological impairment most nearly approximates the current 10 percent evaluation assigned for mild or moderate incomplete paralysis of the posterior tibial nerve. The May 2007 and May 2012 VA examiners both identified a decrease in sensation along the surface of the right foot and the Veteran reported in May 2012 experiencing some radiating numbness to the first and second toes. There is no evidence of a motor deficit, and the Veteran's neurological involvement is sensory in nature. As noted above, in such cases a rating in excess of mild or moderate severity is not appropriate. 38 C.F.R. § 4.124a. The May 2012 VA examiner also specifically found that the Veteran's disability manifested neuropathy that was consistent with only mild sensory nerve entrapment. An April 2009 statement from the Veteran's private podiatrist noted that the Veteran's right foot condition was chronic and not likely to improve, but the podiatrist did not describe any specific impairment associated with the disability other than noting a general loss of dorsal ligamentous structure and possible involvement of the neurovascular bundle. The Board has also taken into account the Veteran's reports of pain in his right foot, and while the May 2012 VA examiner identified some functional impairment to standing and walking associated with right foot pain, the Board notes that the Veteran has continued to work as a letter carrier with the United States Postal Service (USPS) throughout the claims period walking approximately 15-20 miles per day. Thus, the competent evidence of record, including the Veteran's lay statements, establishes that the service-connected right foot disability most nearly approximates mild to moderate incomplete paralysis under Diagnostic Code 8725 and is contemplated by the current 10 percent evaluation. The Board has also considered whether an increased or separate rating is warranted under Diagnostic Codes 5276-5284 pertaining to orthopedic disabilities of the foot. Initially, the Board notes that while the Veteran has consistently complained of pain, weakness, and stiffness in his foot, these complaints are contemplated by the current 10 percent rating under Diagnostic Code 8725. The Veteran's service-connected right foot disability has not manifested orthopedic symptoms that are separate and distinct from the criteria contained in Diagnostic Code 8725, and a separate rating is not warranted. See 4.14, Esteban v. Brown, 6 Vet. App. 259, 262 (1994). With respect to whether an increased rating is appropriate under Diagnostic Codes 5276-5284, the Veteran's service-connected disability does not manifest any foot conditions such as pes planus, a weak foot, or hammertoes. Although slight pes cavus was observed by the VA examiner in May 2007, the most recent VA examination in May 2012 was negative for any other foot abnormalities and there are no other findings of pes cavus in the record. The disability was previously rated under Diagnostic Code 5279 for metatarsalagia, but a 10 percent evaluation is the maximum rating possible under this diagnostic code. Diagnostic Code 5284 provides for an increased 20 percent evaluation for moderately-severe foot injuries, but the clinical evidence associated with the disability has demonstrated full range of motion of the foot, no evidence of abnormal weight-bearing, and normal appearance of the foot. X-rays of the right foot conducted throughout the claims period have also been normal. Therefore, the disability clearly does not most nearly approximate a moderately-severe foot injury under Diagnostic Code 5284 and an increased rating is not warranted under Diagnostic Codes 5276-5284 pertaining to the foot. The Veteran's representative also argued in December 2009 that a rating under Diagnostic Code 5003 for degenerative arthritis was appropriate. While a private physician diagnosed arthritis of the Veteran's right and left big toes in December 2005, X-rays of the right foot performed throughout the claims period have been consistently normal. Diagnostic Code 5003 requires degenerative arthritis established by X-ray findings. The record contains no such evidence and the May 2012 VA examiner specifically found that imaging results of the Veteran's right foot were normal. Thus, an increased or additional separate rating for orthopedic impairment associated with the right foot disability is not appropriate. The Veteran's service-connected right foot disability also includes scarring associated with the in-service surgery to remove exostosis and a neuroma. As the scar could be productive of separate and distinct symptoms, the Board will consider whether a separate rating is warranted for the service-connected scarring. See 4.14, Esteban at 261-62. Scars are rated under 38 C.F.R. § 4.118, for disorders of the skin under Diagnostic Codes 7801-7805. While the Veteran's claim was pending, new rating criteria for evaluating skin disabilities became effective on October 23, 2008; however, these regulations apply only to claims filed on or after October 23, 2008, or when requested by the Veteran. Although the Veteran did not specifically request review under the revised criteria, he did request a review of his disability rating when he appealed the denial of an increased rating. The Board has an obligation to consider all potentially applicable provisions of law and regulation and to apply the diagnostic criteria in a manner that maximizes his benefits. Schafrath, 1 Vet. App. at 589; Bradley v. Peake, 22 Vet. App. 280 (2008). The revised diagnostic criteria are potentially applicable for purposes of establishing an appropriate rating from October 23, 2008, onward. Hart, 21 Vet. App. at 505. The Board finds that the Veteran's right foot scar associated with his in-service surgery does not warrant a separate compensable rating under the old or current rating criteria for scars. The May 2007 and May 2012 VA examiners identified a surgical scar of the right foot, but the scar was painless, nontender, stable, and clearly did not involve an area greater than 929 sq. cm. In fact, the April 2012 VA examiner measured the scar as 8 x 2 cm. There is also no limitation of motion associated with the scar and the scar is clearly not associated with a burn injury. Additionally, while there was some loss of sensation around the scar, the Board has considered this symptomatology in its discussion above pertaining to neurological impairment associated with the service-connected right foot disability. A separate compensable rating is therefore not possible under Diagnostic Codes 7800-05 (2003) or Diagnostic Codes 7800-05 (2012). In sum, the Veteran's service-connected right foot dorsal exostosis and resection of neuroma warrants a 10 percent evaluation under Diagnostic Code 8725 for mild to moderate neurological impairment of the posterior tibial nerve. A separate or increased rating is not warranted under Diagnostic Code 5003 for arthritis or Diagnostic Codes 5276-5284 pertaining to specific disabilities of the foot. Similarly, a separate compensable rating is not appropriate under the old or revised criteria pertaining to rating scars. The Board has considered whether there is any other schedular basis for granting a higher or separate rating, but has found none. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for an increased rating. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Left Ear Hearing Loss Service connection for left ear hearing loss was granted in a December 2004 rating decision with an initial noncompensable evaluation assigned effective March 29, 2004. The April 2009 rating decision on appeal continued the noncompensable evaluation. The Veteran contends that a compensable rating is warranted as his hearing loss results in difficulty communicating with others. The Veteran also contends that his hearing loss impedes his ability to work as a letter carrier for the USPS, as he cannot hear the approach of customers, motor vehicles, or dogs. The Veteran's left ear hearing loss is currently rated as noncompensably disabling under Diagnostic Code 6100. Evaluations of hearing loss range from noncompensable to 100 percent, based upon 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 puretone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz. 38 C.F.R. § 4.85(a) and (d). To evaluate the degree of disability for service-connected bilateral hearing loss, the Rating Schedule establishes eleven (11) auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85, Diagnostic Code 6100. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The Veteran's most severe left ear hearing loss was measured at the June 2012 VA audiological examination. At that time, he reported having increased communication difficulties due to hearing loss and expressed concern regarding difficulty hearing the approach and attack of dogs during his mail delivery duties. The authorized audiological evaluation indicated pure tone thresholds in the left ear, in decibels, were as follows: HZ 500 1000 2000 3000 4000 LEFT 10 5 10 10 70 The average loss in the left ear was 24 decibels. Speech audiometry revealed speech recognition ability of 92 percent in the left ear. The Veteran was diagnosed with left ear high frequency sensorineural hearing loss. The examiner commented that given the high frequency asymmetric nature of the Veteran's left ear hearing loss, it is expected that he would encounter some localization difficulties and it is also likely that he would encounter occasional difficulty hearing speech and other environmental sounds in adverse environments, particularly in the presence of significant levels of background noise. However, in quieter environments and with good access to visual cues, his hearing loss would not pose a significant barrier to communication and it was further expected that he would be able to function successfully in a work environment with limited functional impact. A puretone threshold average of 24 and a speech recognition score of 92 percent translates to Level I hearing impairment under Table VI. Level I hearing impairment in one ear with normal hearing in the other ear is considered noncompensably disabling. 38 C.F.R. § 4.85, Diagnostic Code 6100. The Veteran is only service-connected for hearing loss of the left ear. 38 C.F.R. § 4.85(f) provides that if impaired hearing is service-connected in only one ear, the nonservice-connected ear will be assigned a hearing impairment designation of I, subject to 38 C.F.R. § 3.383. Effective from December 6, 2002, 38 C.F.R. § 3.383 was amended to provide that where hearing impairment in the service-connected ear is compensable to a degree of 10 percent or more and the hearing impairment in the other ear is considered a disability under § 3.385, the hearing impairment in the non service-connected ear will be considered in evaluating the service-connected disability. 69 Fed. Reg. 48148-50 (August 9, 2004) [codified as amended at 38 C.F.R. § 3.383(a)]. As noted above, the hearing impairment in the Veteran's left ear is not to a compensable degree. Therefore, the hearing impairment in the non service-connected right ear is not for consideration in evaluating the service-connected disability. The Board is sympathetic to the Veteran's complaints of hearing loss, but his service-connected left ear hearing impairment has been properly evaluated as noncompensably disabling throughout the evaluation period. Accordingly, an increased schedular rating is not warranted. Other Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. For determining whether a veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008). In evaluating the Veteran's service-connected disabilities, the Board has considered Mittleider v. West, 11 Vet. App. 181 (1998) and attributed all potentially service-connected symptoms to one service-connected condition or another. The Veteran's right foot disability is manifested by pain with walking and standing and mild to moderate neurological impairment with loss of sensation. These manifestations are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's right foot disability and referral for consideration of extraschedular rating is not warranted. Thun, 22 Vet. App. at 111. The rating criteria for hearing loss contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. Some of the effects of the symptoms associated with the Veteran's bilateral hearing loss, specifically the difficulty hearing the approach and attack of dogs during his mail delivery duties, are not contemplated by the rating criteria; therefore, the criteria are inadequate. The next question is whether the Veteran's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." 38 C.F.R. § 3.321. There is no evidence of marked interference with employment or frequent periods of hospitalization associated with the Veteran's left ear hearing loss. Thus, referral for consideration of an extraschedular rating for left ear hearing loss is not warranted. Id. The Board has also considered whether a claim for entitlement to a total disability rating due to individual employability resulting from service-connected disability (TDIU) has been raised by the record. Entitlement to a TDIU is an element of all claims for a higher initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). A claim for TDIU is raised where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). In this case, the record is negative for evidence that the Veteran is unemployable. He is not in receipt of Social Security disability benefits, and has continued to work for the USPS throughout the claims period. The Veteran has reported that pain associated with this right foot disability makes it difficult for him to walk his mail delivery route, but he has also stated that he has not lost any time from work or is unable to perform his duties due to his service-connected disabilities. Therefore, remand of a claim for TDIU is not necessary as there is no evidence of unemployability due to the service-connected disabilities at issue here. Service Connection Claims Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007). When a chronic disease is shown in service sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.309(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). 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). Psychiatric Disorder The Veteran contends that service connection is warranted for an acquired psychiatric disorder, specifically PTSD, as it was incurred due to his active service with the Navy. The Veteran specifically contends that he incurred a psychiatric disorder due to stress caused by his military service in damage control which included fire fighting aboard naval vessels and participation in a helicopter crash and rescue team. First, the Board will turn to the Veteran's contentions regarding the diagnosis of PTSD. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 32 (4th ed.) (1994) (DSM IV)); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred (unless the evidence shows that the Veteran engaged in combat and the claimed stressor is related to combat). 38 C.F.R. § 3.304(f). The evidence establishes that the Veteran does not have PTSD. Although the Veteran's private psychiatric treatment providers have provided some evidence in support of a finding of PTSD, the Board finds that the weight of all the competent evidence of record establishes that the Veteran does not meet the criteria for a diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a). The evidence in support of the Veteran's claim for service connection for PTSD consists of October 2009 letters from a private physician and private therapist noting diagnoses of PTSD. The private health care providers linked the Veteran's PTSD to his service in damage control during active duty. Although the October 2009 letters constitute competent medical evidence in support of the Veteran's claim, the Board finds that they are outweighed by the medical opinions of two VA examiners who conducted psychiatric examinations of the Veteran in March 2009 and April 2012. The VA examiners concluded that the Veteran did not meet the criteria for a diagnosis of PTSD and instead diagnosed a nonspecified mood disorder. Their opinions were based on a full psychiatric examination and review of the Veteran's complete medical records, to include his service and post-service treatment records. They also provided a complete rationale for their opinions. The April 2012 VA examiner specifically found that the Veteran was not exposed to a traumatic event that was persistently re-experienced and did not manifest persistent avoidance of stimuli associated with reported trauma. In contrast, the October 2009 private opinions did not include any discussion of the specific criteria required by a diagnosis of PTSD under 38 U.S.C.A. § 4.125 and the Fourth Edition of the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The Board therefore finds that the opinions of the March 2009 and April 2012 VA examiners outweigh the private medical evidence in support of the claims. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The Board has also considered the statements of the Veteran that he has PTSD. Lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). The specific issue in this case, whether the diagnostic criteria for PTSD have been met, however, falls outside the realm of common knowledge of a lay person. Jandreau, 429 F.3d at 1377 (lay persons not competent to diagnosis cancer). The Veteran is competent to testify as to observable symptoms, but his opinion as to the cause of the symptoms simply cannot be accepted as competent evidence. Id. Psychiatric disorders are by their very nature complex disabilities that require specialized training to properly diagnose. . See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board therefore finds that the Veteran is not competent to diagnose himself with PTSD. In sum, while the record contains some private medical evidence in support of a diagnosis of PTSD, the Board concludes that the opinions of March 2009 and April 2012 VA examiners are more probative to the question of whether the Veteran meets the diagnostic criteria for a diagnosis of PTSD. The Board has also considered the lay statements of the Veteran that he has PTSD, but finds that he is not competent to render a medical opinion in this instance. Thus, the weight of the evidence of record establishes that the Veteran does not have PTSD in accordance with 38 C.F.R. § 4.125(a) (2012). The Board will now turn to the Veteran's other diagnosed psychiatric disorders, a mood disorder and major depression. The Veteran's contentions with respect to these disorders are two-fold. First, he contends that the psychiatric conditions were incurred during active duty service due to various stressful events. Second, he alleges that a psychiatric disorder developed secondary to pain associated with his service-connected right foot disability. Turning first to whether service connection is warranted for an acquired psychiatric disorder on a direct basis, the Board finds that the record clearly establishes the presence of a current disability. The Veteran first complained of depression in September 2003 to his VA primary care physician, and was placed on an anti-depressant. He has continued to receive treatment for anxiety and depression with a private doctor and was diagnosed with a nonspecified mood disorder at VA examinations conducted in March 2009 and April 2012. In addition, an October 2009 letter from a private therapist also notes a current diagnosis of major depression. The record therefore establishes the presence of a chronic acquired psychiatric disorder diagnosed as a mood disorder and major depression. The Board also finds that the record establishes an in-service injury. Service records are negative for evidence of treatment pertaining to a psychiatric disorder, but the Veteran complained of nervousness on an August 1997 dental health questionnaire. He was psychiatrically normal a week later at the August 1997 separation examination and denied experiencing depression, excessive worry, or nervous trouble on the accompanying report of medical history. Although service treatment records only document one instance of complaints related to the Veteran's nerves, the Board notes that his DD-214 verifies that he served in damage control and he has reported stress associated with his job duties. Thus, the Board finds that the combination of the service records and lay statements are sufficient to establish an in-service injury. With respect to whether the record demonstrates a nexus between the Veteran's current disability and in-service injury, service records do not indicate such a link. As noted above, no chronic psychiatric conditions were noted at any time during service and the Veteran was psychiatrically normal at the August 1997 separation examination. While he complained of nervousness at the beginning of August prior to a dental examination, he specifically denied experiencing depression or nervousness a week later on the separation report of medical history. There is also no medical evidence of psychiatric symptoms or treatment until years after active duty service. The Veteran first complained of depression in September 2003 at the Oklahoma City VAMC and began treatment with an anti-depressant. Since that time, he has received treatment with several private physicians and therapists for anxiety and depression associated with job stress and issues with his family relationships and wife's health. The competent medical evidence is also clearly against the claim for direct service connection. The only medical evidence in support of the claim consists of an October 2009 letter from the Veteran's private therapist. While the content of the letter is concerned solely with linking PTSD to service, the therapist also noted a finding of major depression. The Board interprets the medical opinion as also linking major depression to service, though no specific argument or basis for this conclusion was provided within the body of the letter. None of the Veteran's other health care providers have identified a nexus between a psychiatric disorder and any incident of active duty service, and March 2009 and April 2012 VA examiners provided medical opinions against direct service connection. Both VA examiners identified numerous post-service stressors that contributed to the Veteran's psychiatric disorder including nonservice-connected health problems, job stress, a job injury, and marital and family conflicts. The April 2012 VA examiner also specifically found that the Veteran's mood disorder was less likely than not caused by the Veteran's active duty service. The opinions of the March 2009 and April 2012 VA examiners clearly outweigh the general and non-specific findings of the private therapist. Furthermore, the Veteran has not reported a history of continuing symptoms since service. As noted above, treatment records do not document any complaints of psychiatric symptoms until six years after discharge and the Veteran has not reported experiencing psychiatric symptoms since active duty. The Board discusses the Veteran's reported symptoms in the context of using lay evidence to prove the nexus element of a service connection claim under 38 C.F.R. § 3.303(a) and (d), but not 38 C.F.R. § 3.303(b). See Davidson, 581 F.3d 1313; Walker, 708 F.3d at 1331. The Board has also considered the Veteran's statements connecting his acquired psychiatric disorder to active duty service. The Board notes that lay persons are competent to provide opinions on some medical issues. See Kahana, 24 Vet. App. at 428. The specific issue in this case, however, falls outside the realm of common knowledge of a lay person. Jandreau, 429 F.3d at 1377. The Veteran is competent to testify as to observable symptoms, but his opinion as to the cause of the symptoms simply cannot be accepted as competent evidence. Id. The competent evidence of record is therefore against a nexus between the Veteran's psychiatric disorders and active duty service. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim for service connection on a direct basis. The Board must now determine whether service connection is warranted for the diagnosed mood disorder and major depression on a secondary basis. The Veteran contends that pain associated with his service-connected right foot disability has caused or aggravated his psychiatric conditions. The only medical evidence in support of the claim is a notation in a September 2008 private therapy record, when the treating therapist noted that the Veteran's chronic pain led to increased depression. However, the probative value of this evidence is lessened as the therapist did not note the specific cause of the Veteran's chronic pain. Although the Veteran has reported experiencing severe pain in his right foot, the other treatment records from the therapist record complaints of pain associated with a work-related injury to the Veteran's ankle. The Board finds that the September 2008 notation by the private therapist is simply too vague to constitute probative evidence in support of the claims. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim). Weighing against the claim for service connection on a secondary basis are the opinions of the March 2009 and April 2012 VA examiners. After examining the Veteran and reviewing the evidence, both VA examiners concluded that the Veteran's mood disorder was not incurred secondary to the service-connected right foot disability. Although the Veteran had some anxiety and depression due to chronic disabilities (including his right foot), the VA examiners found that it was not of sufficient severity to account for the Veteran's current condition. In addition, both VA examiners noted the Veteran's mood disorder was related to his post-military stressors such as problems at work and family troubles. The VA examiners fully explained their findings and made specific reference to other evidence in the claims file in support of their conclusions. Their opinions are therefore entitled to significant probative weight. See Nieves- Rodriguez, supra. The Board has also considered the statements of the Veteran regarding secondary service connection, but again notes that specific issue in this case, i.e. the etiology of a psychiatric disability, falls outside the realm of knowledge of a lay person. Jandreau, 429 F.3d at 1377. The Veteran is competent to report his current symptoms, such as anxiety and depression, but his opinion as to the cause of the symptoms simply cannot be accepted as competent evidence. Id. In sum, the post-service medical evidence of record shows that the first evidence of the Veteran's claimed disability was years after his separation from active duty service. In addition, the weight of the competent evidence of record is against a relationship between the Veteran's disability and active duty service or the service-connected right foot disability. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim and it is denied. 38 U.S.C.A. § 5107(b). GI Disability The Board finds that service connection is warranted for the Veteran's claimed GI disorder as an undiagnosed illness in accordance with 38 C.F.R. § 3.317. VA is authorized to pay compensation to any Persian Gulf veteran suffering from a "qualifying chronic disability." A "qualifying chronic disability," includes (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2)(B). To obtain service connection for an undiagnosed illness or combination of undiagnosed illnesses, a veteran needs to show (1) that he or she is a Persian Gulf veteran; (2) who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) that have become manifest either during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016 and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a). Manifestations of an undiagnosed illness or multisymptom illness include, but are not limited to, fatigue, headache, muscle pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, sleep disturbances, GI signs or symptoms, cardiovascular signs or symptoms, or abnormal weight loss. 38 C.F.R. § 3.317(b). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period are considered chronic. 38 C.F.R. § 3.317(a)(ii)(4). The Board finds that the Veteran served in Southwest Asia. Although service records do not provide details regarding the Veteran's service, his DD-214 establishes that he received the Southwest Asia Service Medal with bronze star. The Board will resolve all doubt in the Veteran's favor and find that he is a Persian Gulf veteran. The Veteran also exhibits objective indications of chronic GI disability. VA examiners who physically examined the Veteran in October 2010 and May 2012 found that there was insufficient clinical evidence to warrant a diagnosis of a chronic disability, but 38 C.F.R. § 3.317 only requires that the record establish objective indications of chronic disability. Objective indications of a chronic disability include both "signs" in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(2)(ii)(3). The Veteran has consistently reported the occurrence of GI symptoms since active duty service, to include abdominal cramps, diarrhea, vomiting, and increased salivation. In an October 2005 statement, his mother also reported that the Veteran experienced frequent stomach problems. The symptoms described by the Veteran and his mother are specifically listed as a manifestation of an undiagnosed illness capable of service connection. 38 C.F.R. § 3.317(b). Thus, the competent lay reports of GI disturbances constitute objective indications of a chronic GI disability. The Board must now determine whether the objective indications became manifest during active military service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016. Review of the Veteran's service records shows that his chronic GI disability was clearly not manifest during his service in Southwest Asia. In January 1996, he was treated for complaints of an upset stomach, vomiting, and diarrhea and was diagnosed with gastroenteritis. The next day, the Veteran was asymptomatic and his condition was characterized as resolved. There is no other evidence of a GI disorder during service, and examination of the Veteran's abdomen was normal at the August 1997 separation examination. The Veteran also specifically denied experiencing any stomach, liver, or intestinal trouble on the accompanying report of medical history. Therefore, the Veteran's claimed undiagnosed illness did not manifest during active military service in the Southwest Asia theater of operations during the Persian Gulf War. Service connection is only possible for the claimed undiagnosed illness if the evidence establishes that it manifested to a degree of 10 percent or more not later than December 31, 2016. The Veteran's GI complaints are not listed in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (2012). However, for the purposes of determining the appropriate rating for the claimed disability, the Board will use Diagnostic Code 7319 pertaining to irritable colon syndrome (spastic colitis, mucous colitis, etc.). Under this diagnostic code, a 10 percent evaluation is assigned for a moderate disability with frequent episodes of bowel disturbance with abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319 (2012). Review of the post-service medical evidence shows that the Veteran first complained of abdominal cramps and diarrhea during a January 2005 visit to his private physician. Upon VA examinations in October 2010 and May 2012, he reported experiencing symptoms of an abdominal condition since service manifested by symptoms such as stomach cramps, diarrhea, increased salivation, and vomiting. The May 2012 VA examiner specifically found that the Veteran experienced frequent episodes of bowel disturbance with abdominal distress and seven or more episodes of the condition within the last 12 months. The competent medical and lay evidence establishes that the Veteran's claimed GI disability most nearly approximates the criteria associated with a 10 percent rating under Diagnostic Code 7319, and has therefore manifested to a degree of 10 percent or more not later than December 31, 2016. Finally, the evidence establishes that the symptomatology identified by the Veteran cannot be attributed to any known clinical diagnosis. Based on the Veteran's GI complaints in January 2005, his private physician diagnosed gastroesophageal reflux disease (GERD); however, this diagnosis was not based on any objective testing. The physician also did not inquire into the history of the Veteran's condition and rendered the diagnosis based solely on the Veteran's one-time complaints of abdominal cramps and diarrhea. In contrast, the October 2010 and May 2012 VA examiner both found that the Veteran's GI problems could not be attributed to a chronic disorder. The October 2010 VA examiner noted that the Veteran's symptoms were not consistent with gastroenteritis and the May 2012 VA examiner also specifically found that the Veteran had an undiagnosed illness. The Board finds that the conclusions of the October 2010 and May 2012 VA examiners outweigh the diagnosis of GERD rendered by the Veteran's private physician in January 2005. The balance of the evidence therefore establishes that the Veteran's symptomatology cannot be attributed to any known clinical diagnosis. The criteria for an award of service connection under 38 C.F.R. § 3.317 are all present, and service connection is warranted for the claimed GI disorder as an undiagnosed illness. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006); Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). With respect to the claim for entitlement to service connection for a GI disorder, VA has substantially satisfied the duties to notify and assist. To the extent that there may be any deficiency of notice or assistance, there is no prejudice to the Veteran in proceeding with this appeal given the favorable nature of the Board's decision to grant the claim. Notice with respect to the other claims was provided in May 2004, July 2008, September 2008, and November 2008 letters. The claims were subsequently readjudicated, most recently in an April 2013 supplemental statement of the case. Mayfield, 444 F.3d at 1333. VA has also met the duty to assist. VA has obtained records of treatment reported by the Veteran, including service treatment records, records of VA treatment, and private medical records. Additionally, the Veteran was provided proper VA examinations in response to his claims for increased ratings and service connection. The VA audiological examinations included the examiner's description of the functional effects caused by the Veteran's hearing disability. Martinak v. Nicholson, 21 Vet. App. 447 (2007). With respect to the claim for an increased rating for the Veteran's right foot disability, the Board ordered in its January 2007, June 2011, and January 2012 remands that the Veteran should be provided a VA examination to determine the neurological impairment associated with the service-connected disability. The ordered examination was scheduled for December 2012, but the Veteran failed to appear for the examination and has not provided any bases for his failure to appear. When a claimant fails without good cause to report for a necessary examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination was scheduled in conjunction with a claim for an increase, the claim shall be denied. 38 C.F.R. § 3.655(a), (b). In this case, the December 2012 neurological examination of the right foot was scheduled in connection with the Veteran's claim for an increased evaluation, but the Board will not summarily dismiss the claim. The Veteran had appeared for an earlier examination of the right foot in May 2012, but VA determined that the examination did not address the neurological impairment from the right foot condition with sufficient specificity and was not wholly responsive to the Board's remand instructions. The second December 2012 examination was scheduled as a result, and while the Veteran did not appear, the Board finds that VA has fulfilled its duty to assist the Veteran in providing the opportunity for a neurological examination of the right foot. The Board also finds that the Veteran's claim should be adjudicated based on the evidence of record, rather than a denial under 38 U.S.C.A. § 3.655. With respect to the Veteran's claim for service connection for an acquired psychiatric disorder, the Board notes that the March 2009 and April 2012 VA examinations do not include a medical opinion specifically addressing whether service connection is warranted on a secondary basis due to aggravation of the claimed disability due to a service-connected condition. However, the Board finds that a medical opinion addressing aggravation is not required by the duty to assist. The Veteran has never alleged that a psychiatric disorder was aggravated by the service-connected right foot disability, and there is no competent medical evidence in support of this aspect of the claim. The March 2009 and April 2012 VA examiners noted that the Veteran experienced some anxiety and depression associated with various chronic medical conditions, but identified several nonservice-connected disabilities (such as back and ankle conditions) as the cause in addition to the right foot disability. Both VA examiners also noted that the Veteran's pain due to chronic medical problems was not of sufficient severity to account for his mood disorder. These findings clearly do not support the claim for secondary service connection, and actually weigh against the claim. Therefore, they do not activate VA's duty to assist the Veteran with a medical opinion addressing secondary service connection based on aggravation. 38 U.S.C.A. § 5103A(d) (West 2002). ORDER Entitlement to a rating in excess of 10 percent for right foot dorsal exostosis and resection of neuroma is denied. Entitlement to a compensable rating for left ear hearing loss is denied. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and a mood disorder as secondary to a service-connected right foot disability is denied. Entitlement to service connection for a GI disorder as due to an undiagnosed illness is granted. ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs