Citation Nr: 1324059 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 10-21 662 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for bilateral tinnitus. 2. Entitlement to service connection for peripheral artery disease (PAD) of the left leg. 3. Entitlement to a compensable rating for service-connected prostatitis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Hal Smith, Counsel INTRODUCTION The Veteran served on active duty from December 1964 to November 1966, to include service in the Republic of Vietnam. These matters are before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The following determinations are based on review of the Veteran's claims file in addition to his Virtual VA "eFolder." The Veteran was advised in a January 2013 letter that the Veterans Law Judge (VLJ) before whom he had testified in June 2011 was no longer employed by the Board, and that he had the right to an additional hearing. Initially, he responded that he wished to appear before a VLJ of the Board and an additional hearing was scheduled for June 2013. An April VA FORM 21-4138, however, reflects that the Veteran requested cancellation of the hearing and no further scheduling for such. When these claims were before the Board in December 2011, they were remanded for additional evidentiary development. They have now been returned for further appellate consideration. Also addressed by the Board in December 2011 was the claim of service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). Service connection for PTSD was granted upon rating decision in December 2012 and a 50 percent rating was assigned. That issue is no longer on appeal. As to the claim for service connection for PAD of the left leg, the Board, in the December 2011 remand decision, determined that while the record did not include a diagnosis of this condition, the claim would be held in abeyance until completion of the remand instructions. The remand instructions were that if the evidence added to the record subsequent to the remand decision diagnosis of PAD, the Veteran was to be examined to determine the etiology of the same. As the records submitted, to include the Veteran's virtual records, showed no such diagnosis, no examination specific to this condition was conducted. The RO was to readjudicate the claim either way, but review of the December 2012 supplemental statement of the case (SSOC) reflects that this issue was not addressed. Thus, remand of the issue of entitlement to service connection for PAD of the left leg is required in order to fulfill the Board's prior remand instructions. Further details follow below in the REMAND portion of this decision. The issue is remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, tinnitus first manifested during active duty service and has persisted since that time. 2. The Veteran's prostatitis is not manifested by voiding dysfunction or urinary tract infections requiring treatment; his urinary symptoms are the result of his nonservice-connected benign prosthetic hypertrophy (BPH). CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria for a compensable rating for prostatitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.115b, Diagnostic Code (DC) 7527 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). In light of the favorable determination here as to the claim of service connection for tinnitus, any defect with respect to the VCAA is considered non-prejudicial. As to the additional claims of entitlement to service connection for PAD of the left leg and entitlement to a compensable evaluation for prostatitis, VA has a duty under the VCAA to notify a Claimant and any designated representative of the information and evidence needed to substantiate a claim. In this regard, letters to the Veteran from the RO (to include letters in November 2006, December 2006, July 2009, March 2010, and January 2012) specifically notified him of the substance of the VCAA, including the type of evidence necessary to establish entitlement to service connection on a direct and presumptive basis, and of the division of responsibility between the Veteran and the VA for obtaining that evidence. Consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), VA essentially satisfied the notification requirements of the VCAA by way of these letters by: (1) informing the Veteran about the information and evidence not of record that was necessary to substantiate his claims; (2) informing the Veteran about the information and evidence VA would seek to provide; (3) informing the Veteran about the information and evidence he was expected to provide; and (4) requesting the Veteran to provide any information or evidence in his possession that pertained to the claims. In this case, VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claims. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012). The information and evidence associated with the claims file consist of his service treatment records (STRs), VA medical treatment records, private post-service medical treatment records, VA examinations, and statements and testimony from the Veteran and his representative. There is no indication that there is any additional relevant evidence to be obtained by either VA or the Veteran. The United States Court of Appeals for Veterans Claims (Court) held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, to specifically include that a disability rating and an effective date will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the Veteran was provided with notice of this information in the letters dated in November 2006, December 2006, and January 2012 as mentioned above. As reported above, the appellant was afforded the opportunity to testify before the Board in June 2011. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) recently held that 38 C.F.R. 3.103(c)(2) (2012) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ essentially elicited testimony necessary to determine the nature of the appellant's claims on appeal. In addition, she sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Moreover, neither the Veteran nor her representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor has identified any prejudice in the conduct of the Board hearing. By contrast, the appellant, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for benefits. As such, the Board finds that, consistent with Bryant, the DRO and the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. Service Connection - In General Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Where there is a chronic disease shown as such in service or within the presumptive period under § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however, remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2012). This rule does not mean that any manifestations in service will permit service connection. To show 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 as distinguished from merely isolated findings or a diagnosis including the word "chronic". When the disease entity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). The Court has held that, in order to prevail on the issue of service connection, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v West, 12 Vet. App. 341, 346 (1999). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a 'competent' source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with 'unique and readily identifiable features' that is 'capable of lay observation.' See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1) (2012). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff had, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the 'authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence'). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002 & Supp. 2012). 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 (2012). 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). Tinnitus The Veteran seeks service connection for tinnitus on a direct basis. He asserts that he has experienced bouts of tinnitus since the mid 1970s. He experienced rocket firing and loud noises on a daily basis when he was in Vietnam for a period of over 17 months. (Hearing Transcript, pg. 8.) With respect to the issue of current diagnosis, Hickson element (1), VA audiometric examination in 2012 notes that the Veteran has tinnitus. When he filed his claim for such in 2006, he stated that this condition had persisted since military service. At the VA January 2012 audiological examination, the examiner provided an etiology opinion regarding tinnitus, thereby confirming tinnitus diagnoses. In addition, the Veteran has reported that he experiences tinnitus; he is considered competent to report the observable manifestations of this claimed disability. See Jandreau, supra. The Board thus finds the foregoing evidence sufficiently establishes a current tinnitus diagnosis. See Hickson, supra. With respect to Hickson element (2), the Veteran's STRs are silent as to complaints, treatment, or diagnoses relating to tinnitus. Personnel records confirm that the Veteran's military occupational specialty (MOS) was that of a cook. He served in the Republic of Vietnam for a period of over 17 months. The Veteran has consistently reported throughout the record that he was routinely exposed to combat-related noise (e.g., mortars, rockets, machine gun noise, etc) in his capacity as a cook. In fact, he is service-connected for PTSD based upon stressors associated with these inservice experiences. See RO rating decision granting service connection for PTSD in December 2012. In light of the foregoing, the Board readily concedes that the Veteran was likely exposed to acoustic trauma while in the military. Under 38 C.F.R. § 3.303(b) (2012), one method of establishing the second and third Hickson elements is through a demonstration of continuity of symptomatology. Barr, supra; see Savage v. Brown, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302(1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b) (2012). In addition to providing competent and credible statements and testimony to the effect of sustaining acoustic trauma in service, the Veteran has also indicated that he has experienced symptoms of tinnitus since about 1970, and persistently thereafter. In this regard, the Board observes that the lay evidence is not without inconsistencies, as the Veteran did not report having tinnitus in the years post service until filing his claim for such in 2006. However, since that time, he has repeatedly described having chronic symptoms of tinnitus since being exposed to various acoustic trauma while serving in Vietnam. Here, it is important to acknowledge that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. Savage, supra. In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr, Jandreau, and Davidson, supra. Given the subjective nature of tinnitus, it is clear that the Veteran's lay accounts of chronicity and continuity of tinnitus since service are competent. Moreover, in light of type of acoustic trauma he sustained in service as a cook during his period in Vietnam, it does not strain credibility to conclude that symptoms of tinnitus arose inservice and continued thereafter. 38 U.S.C.A. § 1153(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.303(a) (2012); Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Board observes that the file contains a 2012 negative opinion provided by a VA audiologist. However, the opinion is afforded little probative value in that the examiner did not adequately address the Veteran's contention that his tinnitus had been present for many years. He blamed the condition on the Veteran's hearing loss (which he stated was not of service origin), but did not discuss the Veteran's assertions that his tinnitus had been present for many years. Accordingly, with respect to crucial Hickson element (3), nexus or relationship, in view of the Veteran's well-established inservice noise exposure, the Board finds his lay assertions regarding continuity and chronicity of tinnitus, both in and since service, to be similarly competent and credible, as well as indicative that he has had bilateral tinnitus since service as a result of acoustic trauma. See 38 C.F.R. § 3.303(b) (2012). The Board finds that at the very least, there exists an approximate balance of evidence for and against the Veteran's tinnitus claim. When the evidence for and against the claim is in relative equipoise, by law, the Board must resolve all reasonable doubt in favor of the appellant. See 38 U.S.C.A. § 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.102 (2012). Accordingly, with resolution of doubt in the Veteran's favor, the Board concludes that a grant of service connection for bilateral tinnitus is warranted. Increased Ratings - In General 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 & Supp. 2012); 38 C.F.R. Part 4 (2012). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole-recorded history, including service treatment records. 38 C.F.R. §§ 4.2, 4.41 (2012). 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). 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 (2012). An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). Under the laws administered by VA, the Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.3 (2012). Prostatitis The Veteran contends that his service-connected prostatitis is more severe than indicated by his current noncompensable disability rating. The Veteran is currently evaluated under DC 7527. Pursuant to DC 7527, postoperative residuals of prostate gland injuries, infections, and hypertrophy are evaluated as voiding dysfunction or urinary tract infection, whichever is predominant. Voiding dysfunction is evaluated under 38 C.F.R. § 4.115a (2012). Voiding dysfunction is further classified as involving urine leakage, urinary frequency, or obstructive voiding. 38 C.F.R. § 4.115a (2012). For urinary leakage, a 20 percent rating is warranted for urinary leakage requiring the wearing of absorbent materials, which must be changed less than 2 times per day. A 40 percent rating is warranted for urinary leakage requiring the use of absorbent materials which must be changed 2 to 4 times a day. A 60 percent evaluation is warranted for urinary leakage requiring the use of absorbent materials which must be changed more than four times a day. For urinary frequency, a daytime voiding interval between two and three hours, or awakening to void two times per night warrants a 10 percent rating. A 20 percent evaluation contemplates a daytime voiding interval between one and two hours, or awakening to void three to four times per night. A 40 percent evaluation contemplates a daytime voiding interval less than one hour, or awakening to void five or more times per night. For obstructive voiding, a 10 percent rating is warranted with marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of: (1) post void residuals greater than 150cc; (2) uroflowmetry showing markedly diminished peak flow rate (less than 10cc/sec); (3) recurrent urinary tract infections secondary to obstruction; or (4) stricture disease requiring periodic dilatation every 2 to 3 months. A 30 percent rating is warranted where there is urinary retention requiring intermittent or continuous catheterization. 38 C.F.R. § 4.115a also contains the criteria for rating urinary tract infection. A 10 percent rating is warranted for long-term drug therapy, 1-2 hospitalizations per year and/or requiring intermittent intensive management. A 30 percent is assigned for recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. Poor renal function is also to be rated as renal dysfunction. In the April 2007 VA examination, it was noted that the Veteran did not carry a diagnosis of chronic prostatitis. While the veteran complained of urinary symptoms, the examiner opined that this was due to his bladder outlet obstruction. In an addendum, it was noted that the bladder outlet obstruction was not due to the prostatitis. Additional VA examination was conducted in January 2012. The claims file was reviewed by the examiner. The final diagnosis was chronic prostatitis, (currently in remission). The examiner noted that the Veteran had another prostate condition which was likely age-related BPH, with innervated prostate specific antigen (PSA), and possibility of prostate cancer (although the Veteran had several negative biopsies). The examiner further noted that the Veteran's prostatitis was diagnosed after inservice treatment for a sexually transmitted disease (STD), and while he had recurrent symptoms over the years, he had not had any since around 2006 according to his history and his not getting antibiotic treatment for episodes of prostatitis. The examiner further noted that the Veteran's current symptoms of urinary obstruction and urinary incontinence appeared to have started at the same time as his BPH (approximately 2007) when he started having weak stream, urinating 3-4 times during the day, and up to 5 times per night. He also complained of incontinence and dribbling, requiring use of a pad each day. The examiner noted that the Veteran did not have these problems prior to 2006 or 2007 which indicated that these symptoms were not related to his prostatitis which was not active. The Veteran's virtual records include documentation of continued treatment for these symptoms in December 2012. Initially, urinary tract infection based on poor renal function (to be rated as renal dysfunction) is not warranted, in that there is no evidence of such infection during the appeal period. Moreover, as the Veteran's current symptoms are not shown to be related to his service-connected prostatitis, but instead due to his nonservice-connected BPH, residuals of voiding dysfunction due to his prostatitis are not indicated. The Board acknowledges the Veteran's contention that his urinary symptoms are related to his service-connected prostatitis; however, the Board finds that, as a lay person, he is not competent to render such an etiological opinion. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Woehlaert, supra. Moreover, the competent evidence of record demonstrates that his urinary symptoms are related to his nonservice-connected BPH. In this regard, while the Veteran contends that his problems of urinary frequency and incontinence are related to his prostatitis. However, no significant residuals associated with this condition have been reported since service separation. Furthermore, the examiner found that his current complaints were due to another condition. The Board has considered whether staged ratings are appropriate for the Veteran's service-connected back disability; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. See Hart v. Mansfield, 21 Vet. App. at 505. Therefore, the Board finds that the competent and credible evidence of record shows that the Veteran does not have voiding dysfunction due to his service-connected prostatitis. Additionally, a compensable disability rating is not warranted based on urinary tract infections. As such, a compensable disability rating for prostatitis is not warranted. In reaching this decision, the Board finds that, as the preponderance of the evidence is against such claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002 7 Supp. 2012); Gilbert, supra. Other Considerations The Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1) (2012). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected prostatitis with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which his prostatitis is rated. Moreover, the evidence reflects that he currently does not have any symptoms associated with such disability. Therefore, there are no additional symptoms of the Veteran's prostatitis that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected prostatitis. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment, which he denied, or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). ORDER Service connection for bilateral tinnitus is granted. A compensable evaluation for prostatitis is denied. REMAND A December 2011 Board remand requested that if the benefits sought on appeal are not granted, the RO should issue a SSOC. In December 2012, an SSOC was issued that failed to discuss the issue of service connection for PAD of the left leg. It is the Board's conclusion that an immediate remand is required as to that claim in order to fulfill the Board's prior remand instruction. Accordingly, the case is REMANDED for the following action: The AMC/RO should issue an appropriate SSOC that discusses entitlement to service connection for PAD of the left leg. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ FRANK J. FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs