Citation Nr: 1323352 Decision Date: 07/23/13 Archive Date: 08/01/13 DOCKET NO. 09-44 672 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 30 percent for the service-connected renal calculi (recurrent nephrolithiasis), to include consideration of an effective date earlier than November 26, 2007. 2. Entitlement to a higher initial rating for the service-connected lumbar discogenic disease, currently evaluated as 10 percent disabling effective on July 27, 2004, and 20 percent disabling effective on February 25, 2011. 3. Entitlement to an initial rating in excess of 10 percent for the service-connected lumbar discogenic disease on the basis of left lower extremity radiculopathy. 4. Entitlement to service connection for Meniere's syndrome. 5. Entitlement to compensation under 38 U.S.C.A. § 1151 for ruptured discs of the neck. 6. Entitlement to compensation under 38 U.S.C.A. § 1151 for a left shoulder condition also claimed as secondary to ruptured discs of the neck. 7. Entitlement to compensation under 38 U.S.C.A. § 1151 for left carpal tunnel syndrome also claimed as secondary to ruptured discs of the neck. 8. Entitlement to compensation under 38 U.S.C.A. § 1151 for a brain aneurism to include headaches. 9. Entitlement to service connection for a left eye disorder, to include as the residuals of conjunctivitis. 10. Entitlement to a total disability evaluation based on individual unemployability by reason of service-connected disability (TDIU). 11. Whether new and material evidence has been received to reopen the claim of service connection for right ear hearing loss. 12. Entitlement to service connection for right ear hearing loss. 13. Entitlement to a rating in excess of 20 percent for the service-connected duodenal ulcer disease. REPRESENTATION Appellant represented by: Michael A. Steinberg, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Higgs, Counsel INTRODUCTION The Veteran had active service from August 1957 to October 1962. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in July 2008, October 2010, January 2011 and March 2011 by the RO. The Veteran provided testimony at a December 2011 hearing before a Decision Review Officer at the RO, a transcript of which is associated with the VA paper claims file. He also testified at a February 2013 hearing held at the RO before the undersigned Veterans Law Judge, a transcript of which is associated with the Virtual VA claims file. The Virtual VA paperless claims file includes records of VA treatment from August 2002 to March 2012. In the July 2008 rating decision the RO found that new and material evidence had not been received to reopen a claim for service connection for right ear hearing loss; denied the Veteran's claim for a TDIU rating; and assigned an increased rating of 30 percent for the service-connected renal calculi, effective on November 26, 2007. The October 2010 rating decision denied the Veteran's claims for compensation pursuant to 38 U.S.C.A. § 1151; denied the claim for a TDIU rating; denied service connection for Meniere's syndrome; and found that new and material evidence had not been received to reopen the claim of service connection for conjunctivitis of the left eye. The March 2011 rating decision assigned an initial rating of 10 percent for lumbar discogenic disease effective on July 27, 2004, and a 20 percent evaluated for lumbar discogenic disease effective on February 25, 2011; and additionally assigned an initial rating of 10 percent for service-connected left lower extremity radiculopathy. The Veteran appeals for higher initial ratings. An April 2012 rating decision and an April 2012 Statement of the Case addressed the issue of an increased rating for the service-connected duodenal ulcer. The April 2012 rating decision indicated that the issue arose from an October 2010 Notice of Disagreement. However, the October 2010 Notice of Disagreement addresses issues adjudicated in an October 2010 rating decision, which did not include the issue of an increased rating for the service-connected duodenal ulcer. Nevertheless, a May 2012 VA Form 9 is sufficient to constitute a timely Notice of Disagreement with the April 2012 rating decision that assigned a rating of 20 percent for duodenal ulcer disease effective on February 28, 2012. The Board further notes that the Veteran did not raise this issue as a matter on appeal at his February 2013 hearing or discuss it at his earlier December 2010 hearing. Accordingly, the issue will be remanded for a Statement of the Case that post-dates the April 2012 rating decision and May 2012 timely Notice of Disagreement as to the issue of an increased rating for the service-connected duodenal ulcer disease. See 38 U.S.C.A. §§ 7104, 7105; Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). With respect to the claim of service connection for left eye disability, the Board notes that the Veteran was denied service connection for conjunctivitis in rating decisions in May 2003 and April 2004, but did not appeal those decisions. The current adjudication of the issue as reflected in an April 2012 Statement of the Case indicates that the claim was reopened and adjudicated on the merits. See April 2012 Statement of the Case, page 85, last paragraph above issue number 15. The eye disorder for which the Veteran currently claims service connection, however, has been diagnosed at a VA examination as pattern dystrophy of the left eye. This is a different disorder than the conjunctivitis that was addressed in May 2003 and April 2004. The Board finds therefore that this is a new claim and that new and material evidence is not required for adjudication of the appeal as to this issue on the merits. In substance, the new claim has been adjudicated on the merits, with the Veteran having been provided a May 2010 VA examination with a June 2010 addendum opinion. In contrast to the Board's finding that the claim is a new claim, the RO found in its April 2012 Statement of the Case that the claim was reopened based on receipt of new and material evidence. The matter of an increased, compensable evaluation for the service-connected sinusitis (or alternatively restoration of a 10 percent rating), is indicated to be a matter on appeal in an April 2012 Statement of the Case. However, in December 2011, the Veteran, through his representative, wrote that the Veteran had a number of issues on appeal, and requested that one of those issues currently on appeal, specifically the validity of the reduction of the claim for service connection for sinusitis from 10 percent to no percent, be withdrawn from his appeal, for the reason that the Veteran was satisfied with his current noncompensable rating for sinusitis. Further, at his December 2011 hearing, the Veteran indicated that he was satisfied with the noncompensable rating for the service-connected sinusitis in conjunction with the rating of 10 percent for his service-connected deviated nasal septum. The Board therefore concludes that the listing of the issue of an increased rating for service-connected sinusitis in the April 2012 Statement of the Case was not indicated, and the matter does not fall within the Board's jurisdiction. See 38 U.S.C.A. §§ 7104, 7105. The matters of an increased rating in excess of 10 percent for the service-connected tinnitus and a compensable evaluation for the service-connected left ear hearing loss are also addressed in an April 2012 Statement of the Case as matters on appeal. However, there is no rating decision pertaining to these issues, no expression of disagreement, or testimony received either at the Veteran's December 2011 or February 2013 hearing as to these matters. Accordingly, the Board finds that, as the listing of these issues on the April 2012 Statement of the Case to be incorrect, the matters are not within the Board's jurisdiction. See 38 U.S.C.A. §§ 7104, 7105. The RO in October 2010 proposed to reduce the Veteran's rating for a deviated nasal septum from 10 percent to no percent. However, in January 2011, the RO determined that a rating reduction was not appropriate and continued the rating of 10 percent, since the evidence showed that condition had not improved and there was evidence to show greater than 50 percent nasal airway obstruction, bilaterally. The Veteran has not sought an increased rating for the service-connected deviated nasal septum, and there is no rating decision or contention that this matter is on appeal. Further, as discussed, at his December 2011 hearing, the Veteran indicated that he was satisfied with the noncompensable rating for sinusitis in conjunction with the rating of 10 percent for his service-connected deviated nasal septum. As a result, the Board finds that the RO's inclusion of the issue of an increased rating for a deviated nasal septum in the April 2012 Statement of the Case was also not indicated, and the matter is not within the Board's jurisdiction. See 38 U.S.C.A. §§ 7104, 7105. In July 2012, the Veteran, through his attorney, submitted a claim of service connection for a mood disorder, claimed as secondary to his multiple service-connected impairments. As this claim is closely related to the Veteran's claim for a TDIU rating, readjudication of the claim for a TDIU rating will be requested in the remand section of this decision. See Gurley v. Peake, 528 F.3d 1322 (2008) (remand of inextricably intertwined claims warranted for reasons of judicial economy even in absence of administrative error). Additionally, the issue, having been raised by the record, but not adjudicated by the Agency of Original Jurisdiction (AOJ), is not within the Board's appellate jurisdiction, but is referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to a TDIU rating, a higher initial rating for the service-connected discogenic lumbar disease, a higher initial rating for the service-connected radiculopathy of the left lower extremity, an increased rating for the service-connected duodenal ulcer disease, and service connection for a mood disorder are being remanded to the RO. FINDINGS OF FACT 1. Since the April 2004 unappealed RO denial of the claim of service connection for right ear hearing loss, evidence was received that was not previously submitted to agency decisionmakers and, when considered with previous record, relates to an unestablished fact necessary to substantiate the claim, is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim, and raises a reasonable possibility of substantiating the claim. 2. The service-connected right ear hearing loss disability is shown as likely as not to be due to the Veteran's period of active service. 3. The Veteran is not shown to have Meniere's syndrome that began during active service or is related to an event or incident of his period of active service. 4. The Veteran is in receipt of the highest schedular rating, 30 percent, assignable under either Diagnostic Code 7508 or 7509, for his recurrent nephrolithiasis; he does not have albuminuria with edema or definite decrease in kidney function, or hypertension attributable to kidney dysfunction. 5. The earliest ascertainable date of an increase in severity of the service-connected recurrent nephrolithiasis, within the one year of the filing the claim for increase, is October 16, 2007. 6. The Veteran is not shown to have Meniere's syndrome that began during active service or is related to an event or incident of his period of active service. CONCLUSIONS OF LAW 1. New and material evidence has been received since the April 2004 RO rating decision to reopen the Veteran's claim of service connection for a right ear hearing loss. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2012). 2. By extending the benefit of the doubt to the Veteran, his disability manifested a right ear hearing loss is due to disease or injury that was incurred his period of active service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2012). 3. The Veteran does not have a left eye disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 4. The Veteran does not have a disability manifested by Meniere's syndrome due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 5. The criteria for the assignment of an earlier effective date of October 16, 2007, for the grant of a 30 percent rating for the service-connected recurrent nephrolithiasis are met. 38 U.S.C.A. §§ 5107, 5110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.400(o)(2) (2012). 6. The criteria for the assignment of a rating in excess of 30 percent disability rating for the service-connected recurrent nephrolithiasis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.115a, 4.115b including Diagnostic Codes 7508, 7509 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). The Board need not consider whether adequate VCAA notice was provided with respect to whether new and material evidence has been received to reopen a claim for service connection for right ear hearing loss because the Board grants service connection for right ear hearing loss in this decision, an outcome fully favorable to the Veteran's claim. With respect to the claim for a rating in excess of 30 percent for renal calculi, a January 2008 VCAA notice letter explained to the Veteran the evidence necessary to substantiate the claim for an increased rating. This letter also informed the Veteran of his and VA's respective duties for obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The January 2008 VCAA notice letter also explained how a disability rating is determined for a service-connected disorder and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Although the notice was provided after initial adjudication of the claim in December 2007, the claim was readjudicated thereafter. As a result, any defect as to timing of the notice is no more than harmless, non-prejudicial error. Id. A January 2010 VCAA notice letter explained the evidence necessary to substantiate the claims for service connection for a left eye disorder and Meniere's disease. This letter also informed the Veteran of his and VA's respective duties for obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The January 2010 VCAA notice letter also explained how a disability rating is determined for a service-connected disorder and the basis for determining an effective date upon the grant of any benefit sought, and was provided to the Veteran in January 2010, prior to initial adjudication of the claims in October 2010, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In February 2013, the Veteran was afforded an opportunity to present testimony at a hearing before the Board. The contentions on appeal were clarified, testimony relevant to the concepts of service connection, increased ratings and a TDIU rating was elicited, and the undersigned sought to identify and explain any evidentiary deficits and suggested the submission of additional evidence to support the Veteran's claims. The actions of the Veterans Law Judge supplement VCAA and comply with any related duties owed during a hearing. VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c),(d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). With regard to the duty to assist, the claims file contains service treatment records, reports of VA post-service treatment, reports of private treatment, and reports of VA examinations. See 38 U.S.C.A. § 5103A(a)-(d). The Veteran is currently in receipt of SSA retirement benefits. It appears that during an earlier time frame he may have been in receipt of or applied for SSA disability benefits. However, December 2008 correspondence from SSA indicates that the medical records underlying the Veteran's receipt of or application for SSA disability benefits in prior years have been destroyed. As these SSA records have been destroyed and therefore no longer exist, further efforts to obtain them would be futile and are not warranted. 38 U.S.C.A. § 5103A(b)(3). As will be discussed, the VA examinations and opinions in this matter are based on an accurate view of the pertinent medical history, a detailed review of the claims file, examinations with the appropriate medical findings for adjudications of the claims, and fully reasoned explanations for the opinions provided. There is no requirement that a medical examiner comment on every favorable piece of evidence in a claims file. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012); see Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners). The Court stated that examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion. Monzingo, 26 Vet. App. at 105. The examinations and opinions obtained in this matter fulfill these requirements. For these reasons, these examinations are of substantial probative value and fulfill VA's duty to provide examinations and opinions with respect to the claims adjudicated below. The Board further notes that the Veteran is represented by a private attorney, who at the February 2013 hearing expressed the view that the records in the claims file were sufficient for adjudication of the claims on appeal. As explained at the February 2013 hearing, and as will be discussed in the remand portion of this decision, the undersigned is of the view that heretofore unobtained treatment records of the Veteran's private physician specializing in neurology may substantiate the Veteran's claims for an increased rating for the service-connected lumbar discogenic disease and radiculopathy to a degree not achieved by the evidence currently in the claims file, particularly to the extent the representative asserted at the hearing that a 60 percent rating for intervertebral disc syndrome was warranted based on incapacitating episodes; and this might in turn help to substantiate the Veteran's claim for a TDIU rating. Additionally, after review of the VA examination opinion regarding the Veteran's 38 U.S.C.A. § 1151 claims, it is clear that the opinion is not adequate for adjudication purposes, and the evidence currently of record is not adequate to either grant or deny the benefit sought on appeal. Otherwise, the Board has taken the assertions by the attorney that the evidence of record is sufficient for current adjudication at face value and has sought to adjudicate claims based on the evidence of record wherever possible. See also, Overton v. Nicholson, 20 Vet. App. 427, 438 (2006) (appellant's representation by counsel "is a factor that must be considered when determining whether that appellant has been prejudiced by any notice error"). Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed for the addressed claims and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to them. Essentially, all available evidence that could substantiate the claims has been obtained. Standard of Poof and Review of Evidence The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Upon review of the file, the Board notes that the claims file contains VA and private medical records. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the evidence submitted or obtained be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the issues on appeal. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. Each disabling condition shown by a veteran's service records, or for which he seeks a service connection must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence. Determinations as to service connection will be based on review of the entire evidence of record, with due consideration to the policy of the Department of Veterans Affairs to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 C.F.R. § 3.303(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). Generally, in order to prevail on the merits on the issue of service connection, there must be competent evidence of current disability; competent evidence of in-service incurrence or aggravation of a disease or injury; and competent evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). New and Material Evidence--Right Ear Hearing Loss Disability The Veteran seeks service connection for right ear hearing loss. He is service-connected for left ear hearing loss but not for right ear hearing loss. Following notification of an initial review and adverse determination by the Regional Office (RO), a notice of disagreement must be filed within one year from the date of notification thereof; otherwise, the determination becomes final and is not subject to revision except on the receipt of new and material evidence. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. § 3.156. Denials for service connection for right ear hearing loss disability were issued in February 1970, November 2002, May 2003, and April 2004. The Veteran did not submit a Notice of Disagreement within one year of notice of the April 2004 denial and it became final. See 38 U.S.C.A. § 7105. A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material for purposes of deciding whether a claim should be reopened, "the credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). Only in cases in which the newly submitted evidence is "inherently false or untrue" does the Justus presumption of credibility not apply. Duran v. Brown, 7 Vet. App. 216, 220 (1994). As will be discussed, the service treatment records include a diagnosis of "Class B" right ear hearing loss and multiple in-service audiograms that reflected hearing loss. However, at the Veteran's September 1962 service discharge examination, no right ear hearing loss was noted. The April 2004 RO denial, which was the last final denial as to this issue, was on the basis that the evidence failed to show that right ear hearing loss was incurred or aggravated by military service. An October 2010 VA examination report, conducted primarily for the purpose of determining whether the Veteran had Meniere's disease related to active service, noted that the Veteran had right ear hearing loss during active service, but not vertigo and hearing loss together so as to warrant a diagnosis of Meniere's disease. In finding that the Veteran experienced right ear hearing loss during active service, the examiner noted that 1961 service treatment records showed that the Veteran complained of a six-month history of hearing loss. Construed in the manner most favorable to the Veteran, the October 2010 VA examination report includes a medical opinion that the Veteran incurred right ear hearing loss during active service. Accordingly, the October 2010 VA examination report is evidence that is neither cumulative nor redundant and constitutes evidence that raises a reasonable possibility of substantiating the Veteran's claim. As such, this examination report constitutes new and material evidence and is sufficient to reopen the previously denied claim. Merits of the Claim-Right Ear Hearing Loss For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Court of Appeals for Veterans Claims has indicated that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993), citing CURRENT MEDICAL DIAGNOSIS AND TREATMENT, 110-11 (Stephen A. Schroeder et al. eds., 1988). When audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a "disability" at that time, he may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley, 5 Vet. App. at 160. At a July 1957 service enlistment examination, clinical evaluation of the ears was noted to be normal. His hearing acuity was evaluated as 15/15 for whispered voice in both ears. Audiological examination results were not reported. At a September 1959 separation and reenlistment examination, clinical evaluation of the ears was noted to be normal. The Veteran's hearing acuity was evaluated as 15/15 for whispered voice in both ears. Audiological examination results were not reported. The service treatment records show that, in December 1961, the Veteran noted having a hearing loss for several weeks. Tinnitus in the right ear off and on for the past six months was also noted. The Veteran was noted to have experienced ear aches from ages ten to twelve, but none since. The Veteran worked as a driver and was not exposed to hazardous noise. On examination, the right ear canal was clear. The tympanic membrane was normal. Upon testing, it was noted that the Veteran had poor bone conduction in the right ear. He was unable to perform valsalva in the right ear. The Veteran was noted by audiogram and in treatment notes to have "Class B" hearing loss. The audiograms dated on December 8, 1961, December 11, 1961 and December 13, 1961, showed a hearing loss in the right ear, including a threshold of approximately 30 hertz at 500 decibels. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). However, an audiogram dated on January 3, 1962, shows pure tone hearing thresholds that were not so clearly reflective of hearing loss. At his September 1962 medical evaluation separation examination, general examination of the ears was noted to be normal. An audiological evaluation of the right ear showed pure tone thresholds to be -5 decibels at 500 hertz, -5 decibels at 1000 hertz, 0 decibels at 2000 hertz, and 20 decibels at 4000 hertz. Pure tone thresholds at 3000 hertz were not measured. The Veteran was discharged from active service in September 1962, due to being found unfit for general military service as a result of chronic non-allergic rhinitis, as described on his September 1962 service separation examination report. At a VA ear, nose and throat consultation in February 1969, the Veteran's vestibular testing of the right ear was noted to be abnormal. The Veteran was found to have "a kind of cochlear disease" on the right side, and a diagnosis of possible Meniere's syndrome was rendered. At a VA ear, nose and throat examination in January 1970, the Veteran provided a history of right ear hearing loss that began in 1963 and complained of some dizziness that began in 1964. The examiner found that a diagnosis of Meniere's syndrome was not justified at the time of examination. The examiner ordered an audiogram and stated that "[w]hatever hearing loss [was] present [would] be determined by the audiogram." At the subsequently conducted audiological testing, pure tone thresholds in the right ear were those of 55 decibels at 500 hertz, 55 decibels at 1000 hertz, 35 decibels at 2000 hertz, and 60 decibels at 4000 hertz. No follow-up opinion was provided as to whether the hearing loss began during active service or was related to any incident of service. Thus, as of January 1970, and from that time forward, the criteria for right ear hearing loss disability had been met. See 38 C.F.R. § 3.385. At a VA examination in October 2002, the Veteran displayed right ear pure tone hearing thresholds of 55 decibels at 500 hertz, 60 decibels at 1000 hertz, 55 decibels at 2000 hertz, 70 decibels at 3000 hertz, and 80 decibels 4000 hertz. His word recognition was 76 percent in the right ear. A hearing loss of lesser degree was found in the left ear. The VA examiner opined that it was at least as likely as not that the Veteran's history of unprotected military noise exposure contributed to his left ear high frequency hearing loss and tinnitus. However, she opined that it was not at least as likely as not that the right ear sensorineural hearing loss was due to "unprotected military noise exposure." [Sic.] Her reasoning was that "other factors [might] be greater contributors to right ear sensorineural hearing loss." At a June 2003 audiological consult, as indicated in the Virtual VA claims file, the Veteran reported having an abnormal ENG test, characterized by a left beating head shake test and no response to ice water caloric in the right ear. This finding was found to be consistent with a compensated right vestibular paresis. The reported symptoms were indicated by history to have begun in 1961. In a June 2006 private examination report, the treating clinician found the Veteran to have an audiometric configuration and word recognition ability consistent with Meniere's disease. The examiner stated that it was reasonable to assume that the Veteran's hearing loss was due to military noise, but acknowledged the difficulty presented by the normal hearing test at the Veteran's final hearing examination. At a July 2010 VA audiological examination, the pure tone thresholds in the right ear were those of 60 decibels at 500 hertz, 60 decibels at 1000 hertz, 55 decibels at 2000 hertz, 75 decibels at 3000 hertz, and 75 decibels at 4000 hertz. Speech recognition in the right ear was 36 percent. The Veteran was noted to have moderately severe to severe sensorineural hearing loss in the right ear, and poor speech recognition in the right ear. He was also noted to have constant tinnitus. No opinion was provided as to whether the Veteran's right ear hearing loss began during active service or was related to any incident of service. As noted, in an October 2010 VA report of a VA examination, conducted primarily for the purpose of determining whether the Veteran had Meniere's disease related to active service, the examiner noted that he had right ear hearing loss during active service, but not vertigo and hearing loss together so as to warrant a diagnosis of Meniere's disease. In finding that the Veteran experienced right ear hearing loss during active service, the examiner noted that the 1961 service treatment records showed that the Veteran complained of a six-month history of hearing loss. The October 2010 VA examiner reviewed the service treatment records, which include multiple audiograms showing right ear hearing loss, and provided an opinion essentially finding that the Veteran began to experience right ear hearing loss disability during active service. After reviewing the entire record, the Board finds the evidence to be in relative equipoise in showing that the current right ear loss disability as likely as not had its clinical onset during the Veteran's period of active service. In resolving all reasonable doubt in favor of the Veteran, the Board finds that the service connection for the currently demonstrated right hearing loss disability is warranted. Meniere's Syndrome At the July 1957 service enlistment examination, the clinical evaluation of the Veteran's ears was noted to be normal. The Veteran's hearing acuity was evaluated as 15/15 for whispered voice in both ears. Audiological examination results were not reported. The service treatment records are negative for a diagnosis of Meniere's syndrome. At a September 1959 separation and reenlistment examination, clinical evaluation of the ears was noted to be normal. The Veteran's hearing acuity was evaluated as 15/15 for whispered voice in both ears. Audiological examination results were not reported. The service treatment records show that, in December 1961, the Veteran reported noticing a hearing loss for several weeks. Tinnitus in the right ear off and on for the past six months was also noted. It was noted that the Veteran had experienced ear aches from the ages of ten to twelve, but none since. It was noted that the Veteran worked as a driver and was not exposed to hazardous noise. On examination the right ear canal was clear. The tympanic membrane was normal. Upon testing, it was noted that the Veteran had poor bone conduction in the right ear. He was unable to perform valsalva in the right ear. The Veteran was noted by audiogram and treatment notes to have "Class B" hearing loss. Audiograms dated on December 8, 1961, December 11, 1961, and December 13, 1961, showed hearing loss in the right ear, including a threshold of approximately 30 hertz at 500 decibels. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). However, an audiogram dated in January 3, 1962, showed pure tone hearing thresholds that were not clearly reflective of hearing loss. At his September 1962 medical evaluation separation examination, the Veteran's ears were noted to be normal. Audiological evaluation of the right ear showed pure tone thresholds of -5 decibels at 500 hertz, -5 decibels at 1000 hertz, 0 decibels at 2000 hertz, and 20 decibels at 4000 hertz. His puretone thresholds at 3000 hertz were not measured. The Veteran was discharged from active service in September 1962, due to being found unfit for general military service as a result of chronic non-allergic rhinitis, as described on his September 1962 service separation examination report. At a VA ear, nose and throat consultation in February 1969, vestibular testing of the right ear was abnormal. The Veteran was found to have "a kind of cochlear disease" on the right side, and a diagnosis of possible Meniere's syndrome was rendered. At a VA ear, nose and throat examination in January 1970, the Veteran provided a history of right ear hearing loss that began in 1963 and also complained of some dizziness that began in 1964. The examiner noted that, in 1969, a diagnosis of Meniere's syndrome had been considered, but in as much as the ringing started in 1969 and the hearing loss in 1963 and the dizziness in 1964, this diagnosis was questionable. The January 1970 examiner opined that there was a functional element behind the symptoms and that a diagnosis of Meniere's syndrome was not justified at the time of the examination. The records of treatment as shown by the Virtual VA claims file noted that, in April 2003, the Veteran attended a VA audiological consultation and had been referred by his primary care physician with a history of hearing loss, right greater than left, in 1961, after an explosion. He complained of right greater than left decreased hearing secondary to sudden hearing loss of unknown etiology in 1961. The treating audiologist asserted that the Veteran related a questionable history of Meniere's disease, previous symptoms of dizziness (now subsided), and ongoing symptoms of imbalance and tinnitus. The Veteran also reported a chronic history of middle ear pathology; but denied having a significant history of otalgia, ear surgery, tympanic membrane perforations or familial history of hearing loss. The Veteran was interested in hearing better, but was somewhat ambivalent regarding amplification, due to a previous negative experience through Miracle Ear. He was referred for further testing in June 2003. Among the test results in June 2003, it was noted that the Veteran had a mild left beating on a head shake test, 100 percent weakness of the right ear on bilateral bithermal calorics, and no response in the right ear on ice water calorics testing of the right ear. The examiner audiologist found that the abnormal ENG was characterized by a left beating head shake test and no response to ice water caloric in the right ear. These findings were stated by she audiologist to be consistent with a compensated right vestibular paresis. At a July 2003 VA follow-up ear, nose and throat consultation with a staff physician, for the purpose of determining whether the Veteran's hearing loss was correctable by surgery, it was noted that records indicated Meniere's disease since 1961. By history in the records, the Veteran began having episodes of vertigo in 1961,with vertigo, fluctuating hearing loss, oral fullness, and tinnitus. At the July 2003 consultation the Veteran stated that currently he did not have any episodes of vertigo, although his hearing loss had become more severe in his right ear and he was still suffering from tinnitus that had also progressively gotten worse. The impression was that of sensorineural hearing loss greatest in the right ear. It was found that the Veteran would benefit from a hearing aid and was referred for fitting of a hearing aid. To the extent the July 2003 follow-up treatment note reflected an impression that Meniere's disease began during service, in 1961, the Board finds the opinion to be of limited probative value, since the focus of the treatment was to determine whether the Veteran had hearing loss that was correctable by surgery as opposed to hearing aids, and because the treating physician did not identify the records on which the impression was based or state reasons that a diagnosis of Meniere's disease could be made as of 1961. Thus, on careful review, the opinion is found to be of limited probative worth for the purpose of relating the onset of the claimed Meniere's syndrome to service. As noted, an October 2010 VA examination was conducted primarily for the purpose of determining whether the Veteran had Meniere's disease related to active service. The Veteran stated that he had hearing loss in service in the early 1960's that had gotten worse over the last 49 years. He was also noted to have onset of tinnitus in 1961. The report also noted that the Veteran related a history of dizziness with onset in 1964. The Veteran added that the tinnitus, vertigo and dizziness were not constant. The vertigo and dizziness were noted to occur weekly and to last a minute or less. The examiner indicated that there were signs of balance disturbance, that there was repeated upper respiratory disease, and that there were signs of hearing loss and tinnitus. The examiner noted that the Veteran had right ear hearing loss during active service, but not vertigo and hearing loss together so as to warrant a diagnosis of Meniere's disease. The examiner added that the 1961 service treatment records showed that the Veteran complained of a six-month history of hearing loss. On examination in October 2010, the Veteran's gait and balance were normal. The examiner noted that Meniere's disease had been suspected in 1969, as indicated in VA notes in 1970 and that the October 2010 VA examiner diagnosed the Veteran as having active Meniere's disease. However, the October 2010 examiner found that it was less likely than not that the Meniere's disease was caused by or the result of military service. The examiner reviewed the service treatment records and noted that the Veteran had a chronic history of severe rhinitis during active service and was discharged because of this condition. The Veteran's enlistment examination in July 1957 was noted to be normal, and the Veteran complained of hearing loss and tinnitus for the past two weeks in December 1961. The service treatment note was noted to indicate that the Veteran had experienced a right side hearing loss for six months. The examiner reviewed medical literature and noted that the clinical features of Meniere's disease included those of (1) episodic vertigo (true spinning sensation that has an onset and offset), (2) sensorineural hearing loss, and (3) tinnitus. The examiner added that Meniere's disease was a condition that was thought to arise from abnormal fluid and ion homeostasis in the inner ear. He related that Meniere's disease was diagnosed only if patients complained of both episodic vertigo and sensorineural hearing loss. (Emphasis in original.) He recounted that the classic pathologic lesion of Meniere's disease was termed endolymphatic hydrops. He noted that this lesion could be definitely diagnosed only by postmortem histopathological analysis of the temporal bone. He further noted that the exact cause of Meniere's disease was unknown. The examiner concluded that, because vertigo and hearing loss must be present together to make the diagnosis of Meniere's disease, and there was no complaint of vertigo in the service treatment records, it was less likely than not that the Veteran's Meniere's disease was caused by military service. The Board finds the October 2010 VA examination report to be of a high probative value. The report reflects a detailed review of the service treatment records and post-service records of treatment, careful consideration of the criteria for the diagnosis of Meniere's disease, and a well-reasoned explanation. The Board has considered whether the Veteran might have experienced vertigo during active service, but notes that the condition was not mentioned in the service treatment records. The Veteran had been inconsistent in describing the date of onset of vertigo, at times describing the onset in 1961 and, at times, stating that it began in 1964, after active service. These varying accounts tend to undermine the Veteran's credibility and reliability to the extent he claims the vertigo began during active service. To the extent that the Veteran was observed and treated extensively for ear, nose, and throat disease during active service, including for hearing loss and chronic non-allergic rhinitis, symptoms of dizziness were not reported by him during this period. With these considerations in mind, the Board finds that the preponderance of the evidence is against the claim in that the Veteran did not experience episodic vertigo (true spinning sensation with that has an onset and offset), one of the elements for a diagnosis of Meniere's disease, during active service. Thus, the factual foundation of the October 2010 VA examiner's opinion, that the Veteran did not experience episodic vertigo during active service, is supported by the evidence, therefore logically giving rise to the conclusion that the Veteran's Meniere's syndrome did not begin during active service or was related to service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). As the preponderance of the evidence shows that the Veteran does not have Meniere's syndrome that began during active service or is related to any incident of service, service connection for Meniere's syndrome must be denied on this record. See 38 C.F.R. § 3.303. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application in resolution of this aspect of the Veteran's appeal. Left Eye Disorder The service treatment records showed that, in March 1959, the Veteran was diagnosed with acute conjunctivitis after being seen for blurry vision. An examination of the eyes revealed that he had 20/25 vision with evidence of a few small follicules in the conjunctivae. In February 1961, during service, the Veteran was again seen for blurry vision, diagnosed as being due to conjunctivitis. At a follow-up examination about three days later, it was noted that the condition was resolving. A treatment report, dated on April 19, 1961, indicated that the Veteran reported his eyes were burning due to driving several hundred miles. At a follow-up examination three days later the condition was noted to be resolving. The report noted slight bulbar conjunctiva. At his September 1962 service separation examination, a clinical evaluation of the eyes, including visual acuity and refraction, was evaluated as normal. Both his near and distant vision were indicated to be 20/20, uncorrected, in both eyes. In connection with VA treatment in August 2002 through March 2012, there were no findings of conjunctivitis. However, in May 2003 the Veteran reported having black spots at the back of his left eye. He received treatment for pattern dystrophy and dry eyes. A treating ophthalmologist in May 2003 noted several small dots of hyperpigmentation in the posterior pole of the left eye including the fovea. There was no exudation. There was a mild hypopigmented halo around the lesions. The treating physician's impression was that of pattern dystrophy. The Veteran was to return for care once a year as need for symptoms. At a VA allergy consultation in September 2009, an examination of the eyes revealed no conjunctivitis, blepharitis, or drainage. At a VA examination in May 2010, the Veteran was diagnosed as having pattern dystrophy in the left eye greater than in the right. In a June 2010 VA examination addendum report, the examiner opined that, based on the available evidence noted in the service treatment records, the ophthalmological examinations conducted at the Tamp VA Medical Center from 2003 to 2009, and the examiner's own examination of the left eye, the Veteran's left eye disorder was not caused by or the result of any ocular conditions or treatment documented during his active duty military service. In the examiner's view, as was noted on the Veteran's 1959 reenlistment physical, his treatment for conjunctivitis of the left eye required hospitalization, but according to that document, there were no complications or sequelae. The examiner noted that, at the time of the 1959 reenlistment physical, the Veteran's eyes were noted to be 20/20, bilaterally. The examiner noted additionally that the Veteran's unaided visual acuity was also noted to be 20/20, bilaterally, at the time of the September 1962 service separation physical. The VA examiner noted that, in 2003, and subsequently, the Veteran was found to have decreased vision in the left eye compared to the right eye when examined at the Tampa VA eye clinic. The examiner noted that the Veteran was diagnosed as having pattern dystrophy, left eye greater than right eye, and that this was not related to an ocular injury the Veteran reported while chiseling in California during his period of active duty in the late 1950's. The VA examiner noted that part of the history in a 2003 Tampa VA eye clinic record included the treating clinician recorded history of having subnormal vision since his 20's and being told he had a "lazy eye" when he left the service. The examiner noted, however, that the Veteran's 1962 in-service separation physical documented 20/20 unaided visual acuity of the left eye. The examiner added that there was no history of any retinal problems in the service treatment records. A January 2011 VA allergy clinic note noted that an examination of the eyes revealed that the pupils were equal, round, and reactive to light and accommodation, and that there was no conjunctivitis. The Board finds that the May 2010 VA examination report, as supplemented by the June 2010 VA addendum opinion, included a detailed examination of the Veteran, an accurately recorded history, a review of the claims file, and a well-supported explanations by the clinician who was a specialist in the appropriate field medicine. Accordingly, the examination report is afforded a high probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (VA medical examiners and private physicians offering medical opinions in veterans benefits cases are nothing more or less than expert witnesses; most of the probative value of a medical opinion comes from its reasoning). Thus, the examiner's opinion constitutes competent evidence of very substantial probative weight that the Veteran's current left eye disability is due to pattern dystrophy that was not present during his period of active service or related to any event or incident of service. The Board acknowledges the Veteran's assertions of having weak vision in the left eye beginning in service. However, these assertions are of limited credible and probative worth when he viewed in connection with the objective evidence recorded in service and thereafter. He did experience eye symptoms significant enough to warrant hospitalization during the early part of his service, but these manifestations were noted to be resolving in the subsequent medical evidence. Moreover, at the time of his discharge from service, the Veteran did not exhibit findings of any eye pathology or visual impairment. As noted, the probative VA examination in 2010 identified that his current left eye condition was properly diagnosed as pattern dystrophy and was not related to any disease or injury that happened during his period of active service. In sum, the Board finds that the in-service results of treatment and service examinations showing that the Veteran's conjunctivitis had resolved and the recently obtained VA medical opinion outweigh the Veteran's assertions of having eye or visual problems that began in service and continued thereafter. As the preponderance of the evidence is against the claim, service connection for a left eye disorder must be denied, and the benefit of the doubt rule is not for application in this matter. Increased Rating-Kidney Stones Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating the severity of a particular disability it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim, if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's renal calculi are currently evaluated as 30 percent disabling under 38 C.F.R. § 4.115b, Diagnostic Code 7509. Under DC 7508, nephrolithiasis is rated as hydronephrosis (DC 7509), except when a veteran has recurrent stone formation requiring one or more of the following: diet therapy; drug therapy; or, invasive or non-invasive procedures more than two times a year, when a 30 percent evaluation is assignable. 38 C.F.R. § 4.115b. Diagnostic Code 7508 directs that, when a compensable rating is not available under Diagnostic Code 7508, one should be considered under Diagnostic Code 7509. Under Diagnostic Code 7509, hydronephrosis, when there is only an occasional attack of colic, and there is no infection or need for catheter drainage, will be rated as 10 percent disabling. When there are frequent attacks of colic, requiring catheter drainage, a 20 percent rating is warranted. A 30 percent evaluation is assignable for hydronephrosis with frequent attacks of colic with infection (pyonephrosis), with kidney function impaired. If the disability is severe, it is to be rated as renal dysfunction under 38 C.F.R. § 4.115a. 38 C.F.R. § 4.115b. Higher ratings may be available where a greater degree of kidney dysfunction is shown. Renal dysfunction is rated as 60 percent disabling where there is constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101. An 80 percent rating is warranted where there is persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted where the condition requires regular dialysis, or precludes more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. The examination results from the Tampa VA Medical Center, dated on April 21, 2008, noted that the Veteran had a history of obstructive voiding, hydronephrosis and urinary tract stones. The examiner noted that he was on a low calcium diet. The examiner added that the Veteran had had two invasive procedures for kidney stones within the past twelve months. Catheterization was required. The examiner also noted the Veteran had three attacks of colic with infection within the past twelve months. The examiner diagnosed the Veteran with recurrent nephrolithiasis. At a VA examination in August 2010, the examiner noted that the Veteran continued to pass kidney stones once or twice a month. The report noted three or more invasive procedures in the past twelve months, and the Veteran was had been prescribed a low calcium diet. The report included a diagnosis of recurrent renal calculi. The examiner noted that the Veteran was not physically restricted by this condition and added that the Veteran's kidney stone condition could be painful when the Veteran passed a stone one to two times per month. At a February 2012 VA examination, the Veteran was noted to have occasional attacks of colic causing hydronephrosis. The examiner noted that, when the Veteran did have kidney stones, he was unable to work due to severe pain and being on pain medications. The examiner reported that the Veteran would get stones approximately once a month, lasting one to seven days. The Veteran is in receipt of the highest schedular rating, 30 percent, assignable under either Diagnostic Code 7508 or 7509, for his recurrent nephrolithiasis. A rating in excess of 30 percent is not warranted unless kidney function is more severely impaired. In this case the preponderance of the evidence shows that, for the period of the appeal, the evidence does not show the presence of underlying renal dysfunction. There was no albuminuria with edema or definite decrease in kidney function; nor was hypertension attributable to kidney dysfunction and ratable as at least 40 percent disabling (moreover, the Veteran's diastolic pressure has generally been in the 70 to 100 range and has approached the criterion for 40 percent (120), see Diagnostic Code 7101), as would be required for a 60, 80 or 100 percent rating pursuant to 38 C.F.R. § 4.115a. As a result, the preponderance of the evidence is against the claim for a rating in excess of 30 percent for the period of this appeal, and a staged rating higher than 30 percent is not warranted for any period subject to this appeal. On this point, the Veteran notes that, at his February 2013 hearing, he did not report experience ongoing kidney impairment, but rather related having his symptoms primarily consisting of recurrent and very painful kidney stones. For increased rating claims, an effective date may be awarded prior to the date of the claim if the increase in disability became factually ascertainable within the one-year time period immediately preceding the claim. 38 U.S.C.A. § 5110 (b)(2); 38 C.F.R. § 3.400(o)(2). When the Veteran filed his claim for an increased rating in November 2007, he referenced an October 16, 2007, episode of private hospital treatment for his condition. The records of private hospital treatment from Bartow Hospital had been obtained and associated with the claims file. The Veteran in this instance was treated at the emergency room for an episode of kidney stones. He described having the pain as 10 on a scale of one to ten and the having had an onset of two days earlier. A CT scan of the abdomen showed bilateral renal calculi but no evidence of hydronephrosis. In resolving all reasonable doubt in favor of the Veteran, the Board finds that the period of hospitalization beginning on October 16, 2007, represents an earliest ascertainable date that a worsening of the Veteran's kidney condition within the one year prior to receipt of his claim for increase. Accordingly, an earlier effective date of October 16, 2007, is assignable for the current 30 percent rating for the service-connected recurrent kidney stones. The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the Veteran's service-connected recurrent nephrolithiasis. The governing norm in such exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). At his February 2013 hearing, the Veteran testified that he had experienced kidney stones up to twice per month, but did not have frequent kidney infections or other kidney disease as a result. The symptoms of the Veteran's recurrent nephrolithiasis, consisting primarily of the frequent passing of kidney stones and need for medical treatment including multiple invasive procedures during some years as a result, are directly contemplated by the rating criteria. Accordingly, the Board finds that this case does not warrant referral for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b). ORDER To the extent that new and material evidence has been presented to reopen the claim, service connection for right ear hearing loss disability is granted. Service connection for a left eye disorder is denied. Service connection for Meniere's syndrome is denied. An earlier effective date of October 16, 2007, but no sooner for the assignment of a rating of 30 percent for the service-connected recurrent nephrolithiasis is granted, subject to the regulations controlling disbursement of VA monetary benefits. An increased rating in excess of 30 percent for the service-connected recurrent nephrolithiasis is denied. REMAND At the February 2013 hearing, the Veteran's representative asserted that a 60 percent rating was warranted for the service-connected intervertebral disc syndrome based on incapacitating episodes. The Veteran described having treatment with a former VA, but now private physician, who recommended bed rest at times. The correspondence from indicates that the physician was then in a private neurology practice. The recent records of private treatment might serve to substantiate the Veteran's claim and should be sought. See 38 U.S.C.A. § 5103A(a)-(c). Also, a February 2012 VA examination report indicated that the Veteran did not have IVDS, i.e., intervertebral disc syndrome, and, as a result, no opinion as to whether the Veteran experiences incapacitating episodes due to intervertebral disc syndrome was rendered. The diagnosis of discogenic disc disease with associated radiculopathy would also be sufficient to constitute intervertebral disc syndrome. The matter of whether the Veteran has IVDS and if so whether he experiences incapacitating episodes as a result requires clarification. See 38 C.F.R. § 4.2 (VA examination reports-corrective action); Colvin v. Derwinski, 1 Vet. App. 171 (1991) (the Board is not competent to supplement the record with its own unsubstantiated medical conclusions, and if the medical evidence of record is insufficient, VA is always free to supplement the record by seeking an advisory opinion, or ordering a medical examination to support its ultimate conclusions). The treatment records will also be relevant to the proper rating for the Veteran's radiculopathy, whether rated separately from limitation of range of motion of the thoracolumbar spine or in the context of incapacitating episodes. See 38 C.F.R. § 4.71a, General Rating Formula for Disease and Injuries of the Spine, and Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. With respect to the Veteran's claim for disability compensation pursuant to 38 U.S.C.A. § 1151, as result of VA hospitalization and surgery in July 2004, a VA examiner has opined that he could find no evidence of carelessness, negligence, etc., resulting in a neck disorder, a left shoulder disorder or carpal tunnel syndrome. He stated that complications did happen sometimes after surgeries, but this by itself did not mean carelessness, and he could find no evidence of carelessness in this case. The Board has previously adjudicated the Veteran as entitled to additional compensation pursuant to 38 U.S.C.A. § 1151 for discogenic disc disease and radiculopathy that were as likely as not aggravated by the VA hospitalization and treatment in July 2004, on the basis that no fault on the part of VA was shown, but the additional disability was due to events not reasonably foreseeable. However, the June 2010 VA examiner did not indicate in his opinion whether the Veteran had additional disability including carpal tunnel syndrome, a left shoulder condition, or ruptured discs of the neck were a result of the VA hospitalization and surgery in July 2004. He also did not discuss at all the Veteran's claimed additional disability of brain aneurysm. Without a finding as to whether the Veteran's claimed conditions constitute additional disability due to or as a consequence of the July 2004 VA treatment and hospitalization, the Board cannot determine whether a medical opinion is required as to whether such claimed additional disability may due to an event not reasonably foreseeable. As a result, the June 2010 VA examination report must be returned for corrective action. See 38 C.F.R. § 4.7; Colvin v. Derwinski, 1 Vet. App. 171 (1991) (the Board is not competent to supplement the record with its own unsubstantiated medical conclusions, and if the medical evidence of record is insufficient, VA is always free to supplement the record by seeking an advisory opinion, or ordering a medical examination to support its ultimate conclusions). As noted, the Veteran's attorney in July 2012 raised a claim of service connection for a mood disorder as secondary to service-connected physical disabilities. The claim is inextricably intertwined with the claim for a TDIU rating. Accordingly, the Board requests adjudication of the claim. See Gurley v. Peake, 528 F.3d 1322 (2008) (remand of inextricably intertwined claims warranted for reasons of judicial economy even in absence of administrative error). Given the grant of service connection for right ear hearing loss, further development in the form of obtaining additional information and evidence from a private neurological specialist, and initial adjudication of the matter of service connection for a mood disorder as secondary to service-connected physical disabilities, will be relevant to the adjudication of the Veteran's claim for a TDIU rating. Accordingly, adjudication by the Board of the claim for a TDIU rating must be deferred and any further appropriate development with respect to the claim should be conducted. As noted, an April 2012 rating decision and Statement of the Case addressed the issue of an increased rating for the service-connected duodenal ulcer disease. To the extent that the October 2010 Notice of Disagreement addressed issues adjudicated in an October 2010 rating decision, this did not include adjudication of this claim for increase. The Board further notes that the Veteran did not raise this issue as a matter on appeal at his February 2013 Board hearing or discuss it at the earlier December 2010 hearing. Nevertheless, a May 2012 VA Form 9 is sufficient to constitute a Notice of Disagreement with the April 2012 rating decision (and the issue as it was erroneously included and presented in the April 2012 Statement of the Case on the same day) that assigned a rating of 20 percent for duodenal ulcer disease effective on February 28, 2012. Accordingly, this matter will be remanded for a Statement of the Case as this issue post-dates the April 2012 rating decision and May 2012 notice of disagreement. See 38 U.S.C.A. §§ 7104, 7105; Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). Accordingly, these remaining matters are REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO should conduct all necessary actions for notice, development, and adjudication of the Veteran's claim of service connection for a mood disorder secondary to his service-connected disabilities. If the claim is denied, the Veteran should be advised of his appellate rights. 2. The RO should take appropriate action, including issuance of a Statement of the Case, on the appeal initiated by the Veteran from the April 2012 rating decision addressing entitlement to an increased rating for the service-connected duodenal ulcer disease. The Veteran and his representative should be clearly advised of the need to file a timely Substantive Appeal if the Veteran wishes to perfect his appeal as to this matter. 3. The RO also should take appropriate steps to contact the Veteran in order to request that he identify the name and address of all health care providers who have rendered medical treatment for the service-connected low back disability and associated radiculopathy and the claimed brain aneurism, ruptured disc of the neck, carpal tunnel syndrome and left shoulder condition. After any required releases for medical information are requested and obtained from the Veteran, an attempt should be made to obtain any records so identified that are potentially available but have not been previously obtained. The records sought should include the records of private treating neurologist who apparently moved from VA to private practice during the course of the appeal and continued to treat the Veteran. The Board anticipates that the relevant records of treatment will date from approximately August 2011 forward. Any additional and potentially relevant records of VA treatment should also be obtained. The Veteran should be advised that, alternatively, he may obtain private records of treatment on his own and submit them to the RO. 4. The RO should take all indicated action in order to an addendum VA medical opinion with respect to the Veteran's claims for additional compensation pursuant to 38 U.S.C.A. § 1151, for the claimed brain aneurism, ruptured disc of the neck, a left shoulder condition, and carpal tunnel syndrome. The opinion should substantially supplement the June 2010 VA medical opinion provided with respect to these claims. The RO should send the claims file to the examiner for review, and the clinician should indicate that the claims file was reviewed. The examiner should be informed that the Veteran is already in receipt of compensation pursuant to 38 U.S.C.A. § 1151 for additional disability resulting from the hospitalization and procedures in July 2004 in the form of degenerative disc disease and radiculopathy to the left lower extremity, adjudicated as being as a result of events not reasonably foreseeable during the July 2004 procedures and hospitalization. The report should include a finding as to whether the Veteran sustained any additional disability in the form of a brain aneurism, a ruptured disc of the neck, a left shoulder condition, or carpal tunnel syndrome, as a result of his VA hospitalization and procedures in July 2004. If it is found that additional disability exists in the form of a brain aneurism, a ruptured disc of the neck, a left shoulder condition, or carpal tunnel syndrome, as a result of his VA hospitalization and procedures in July 2004, the examiner should additionally provide opinions as to whether the additional disability is a result of (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination, or (B) an event not reasonably foreseeable. In all conclusions, the examiner should identify and explain the medical basis or bases, with identification of the relevant evidence of record. The examiner should provide a fully reasoned explanation for his or her opinions, based on established medical principles and his or her clinical experience and medical expertise. 5. Once all available relevant medical records have been received, the RO should make arrangements with an appropriate VA medical facility for medical opinions, or medical examinations, as indicated. The purposes of the examination and/or opinions are two-fold: (1) to determine whether the Veteran has intervertebral disc syndrome (IVDS), and, if so, to provide an opinion as to whether the Veteran experiences incapacitating episodes as a result of IVDS, and (2) to determine whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. The RO should send the claims file to the examiner for review, and the clinician should indicate that the claims file was reviewed, to include a February 2012 report of VA examination. The requested report is intended to supplement the report of a February 2012 VA examination conducted in this matter. If the examiner or the RO determines that re-examination of the Veteran is required to provide the medical opinions requested by the Board, such an examination should be accomplished. The Board notes that, in February 2012, the VA examiner indicated by a checked box that the Veteran did not experience IVDS and, as a result, no opinion as to whether or the extent to which the Veteran experienced incapacitating episodes was provided. The examiner should indicate whether a finding of IVDS is appropriate, and provide a fully reasoned explanation for this finding. If a finding of IVDS is found to be appropriate, the examiner should provide an opinion as to whether or the extent to which the Veteran's experiences incapacitating episodes due to IVDS, with a fully reasoned explanation. In rendering these opinions, the examiner should review any newly obtained private treatment records of the private treating physician (and former VA treating physician) practicing in the area of neurology. The Board anticipates that the records would be for treatment rendered from approximately August 2011 forward. The examiner should additionally provide an opinion as to whether the Veteran is unable to secure or follow a substantially gainful occupation as result of the COMBINED EFFECTS of his service-connected disabilities and disabilities for which he has been afforded additional compensation pursuant to 38 U.S.C.A. § 1151. The examiner should be advised of all service-connected disabilities and disabilities for which the Veteran been afforded additional compensation pursuant to 38 U.S.C.A. § 1151. In all conclusions, the examiner should identify and explain the medical basis or bases, with identification of the relevant evidence of record. The examiner should provide a fully reasoned explanation for his or her opinions, as a matter of medical probability, based on established medical principles and his or her clinical experience and medical expertise. 6. After completing all indicated development to the extent possible, the RO should readjudicate the claims remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnish a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs