Citation Nr: 1326508 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 02-13 676 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an evaluation in excess of 20 percent for residuals of a biopsy, granulomatous, buccal sulcus, on the right side of the mouth. 2. Entitlement to service connection for arteriosclerotic vascular disease, claimed as secondary to an acquired psychiatric disorder. 3. Entitlement to service connection for a low back disorder. 4. Entitlement to an initial compensable evaluation for an inability to wear a partial bridge due to excisional biopsy. 5. Entitlement to service connection for pyloric obstruction, claimed as secondary to an acquired psychiatric disorder. 6. Entitlement to service connection for peptic ulcer disease, claimed as secondary to an acquired psychiatric disorder. 7. Entitlement to service connection for headaches, claimed as secondary to an acquired psychiatric disorder. 8. Entitlement to service connection for hypertension, claimed as secondary to an acquired psychiatric disorder. 9. Entitlement to service connection for a wrist disorder. 10. Entitlement to service connection for an ankle disorder. 11. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Lori Chism, Attorney ATTORNEY FOR THE BOARD Anthony M. Flamini, Counsel INTRODUCTION The Veteran served on active duty from February 1971 to January 1973. The matter of entitlement to an initial compensable evaluation for an inability to wear a partial bridge due to excisional biopsy originally came before the Board of Veterans' Appeals (Board) on appeal from an October 2001 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In the October 2001 rating decision, the RO granted: (1) an increase in the rating assigned for residuals of an excisional biopsy of a granulomatous, buccal sulcus, on the right side of the mouth, from zero to 10 percent; and (2) service connection for an inability to wear a partial bridge due to excisional biopsy, assigning a noncompensable rating for that disorder, effective from March 29, 2001. See 38 C.F.R. § 4.150, Diagnostic Code 9913, regarding the second grant. The Veteran perfected an appeal as to the ratings assigned for both disabilities. In December 2003 the Board remanded the appeal to the RO for further development to include scheduling a VA examination. In a February 2007 decision the Board denied both appealed claims for increased ratings. The Veteran appealed the February 2007 decision of the Board to the United States Court of Appeals for Veterans Claims (Court). In the October 2008 memorandum decision, the Court addressed the two issues on appeal denied in the February 2007 Board decision: (1) entitlement to an increased rating for residuals of an excisional biopsy of a granulomatous, buccal sulcus, on the right side of the mouth, currently evaluated as 10 percent disabling; and (2) entitlement to an initial compensable evaluation for an inability to wear a partial bridge. The Court determined that the record contained a plausible basis, and the Board's decision was supported by an adequate statement of the reasons or bases, for its decision with respect to the claim for a higher disability rating for residuals of an excisional biopsy of a granulomatous, buccal sulcus, on the right side of the mouth. On that basis the Court affirmed that part of the February 2007 decision of the Board. Thus, that part is not before the Board at this time. The Court, however, vacated and remanded to the Board for further development consistent with the Court's decision the part of the Board's February 2007 decision pertaining to the matter of the denial of an initial compensable disability rating for inability to wear a partial prosthesis. In so doing, the Court determined that in its decision the Board did not address or reconcile an apparent conflict between two similar opinions contained in VA examinations of April 2001 and February 2006 VA, and a later April 2006 addendum to the 2006 examination report. The conflict was on a determinative issue as discussed below. The claims file was subsequently transferred to the RO in Waco, Texas, and the remaining matters come before the Board on appeal from a January 2011 rating decision of that office. The issues of entitlement to an initial compensable evaluation for an inability to wear a partial bridge due to excisional biopsy, as well as entitlement to service connection for pyloric obstruction, peptic ulcer disease, headaches, hypertension, a wrist disorder, an ankle disorder, and a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's residuals of a biopsy, granulomatous, buccal sulcus, on the right side of the mouth are manifested by incomplete severe paralysis of the seventh (facial) cranial nerve. 2. The medical evidence of record does not establish that the Veteran is diagnosed with a disability manifested by coronary artery disease or arteriosclerotic vascular disease. 3. The preponderance of the evidence reflects that the Veteran's current low back disorder was not manifested during service, nor has it been shown to be causally related to any aspect of service. CONCLUSIONS OF LAW 1. The criteria for an increased rating in excess of 20 percent for service-connected residuals of a biopsy, granulomatous, buccal sulcus, on the right side of the mouth have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.124a, Diagnostic Code 8307 (2012). 2. The medical evidence of record does not establish that the Veteran is diagnosed with a disability manifested by cardiac symptomatology. 3. A low back disorder was not incurred in or aggravated by the Veteran's active duty service, nor may it be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Duty to Notify and the Duty to Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that or "immediately after" VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Here, with respect to the issues decided herein, the record reflects that the Veteran was provided all required notice in correspondence dated in August 2010, prior to the initial adjudication of the issues in January 2011. In addition, the record reflects that service treatment records and post-service VA and private treatment records have been obtained. Further, the Veteran was afforded appropriate VA examinations. The Board finds that the examination reports are adequate to allow proper adjudication of the issues decided herein. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Collectively, the examiners conducted complete examinations, recorded all findings considered relevant under the applicable diagnostic codes, and considered the full history of the disabilities. There is no indication that the disabilities have increased in severity since the Veteran was last examined in April 2012. Neither the Veteran nor his representative has identified any other evidence that could be obtained to substantiate the claims. The Board is also unaware of any such evidence. Therefore, the Board is satisfied that VA has complied with the duty to assist requirements of the VCAA and the pertinent implementing regulation with respect to the claims decided herein. II. Increased Rating Claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21 (2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Staged ratings are, however, appropriate when the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In September 2009, the Veteran filed a claim for entitlement for an evaluation in excess of 10 percent for his service-connected residuals of a biopsy, granulomatous, buccal sulcus, on the right side of the mouth. He alleged inability to masticate properly as well as issues related to self esteem and disfigurement. Based on the results of a VA examination conducted in April 2012, a December 2012 rating decision increased his evaluation to 20 percent effective September 17, 2009, the date his claim was filed. The Board notes that the Veteran's psychiatric symptomatology has been diagnosed as "nightmare disorder" and separately service connected. The RO has assigned a 20 percent evaluation for the Veteran's residuals of a biopsy, granulomatous, buccal sulcus, on the right side of the mouth under 38 C.F.R. § 4.124a, Diagnostic Code 8399-8307. Hyphenated diagnostic codes and rating by analogy are used when an unlisted disability is at issue. See 38 C.F.R. § 4.27. The first two digits of the first diagnostic code indicate the most closely related body part followed by a "99." Id. Use of the second diagnostic code helps provide further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id.; see Tropf v. Nicholson, 20 Vet. App. 317, 321 (2006). Moreover, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated. Id. The RO assigned a 20 percent evaluation for the Veteran's residuals of a biopsy, granulomatous, buccal sulcus, on the right side of the mouth under Diagnostic Code 8307 for neuritis of the seventh (facial) cranial nerve. Neuritis involving the seventh cranial nerve is evaluated under Diagnostic Code 8307, while neuralgia is evaluated using Diagnostic Code 8407. 38 C.F.R. § 4.124a. Under Diagnostic Code 8207 for paralysis of the seventh (facial) cranial nerve, incomplete moderate paralysis is rated as 10 percent disabling. 38 C.F.R. § 4.124a, Diagnostic Code 8207. Severe incomplete paralysis is evaluated as 20 percent disabling. Id. Complete paralysis is awarded a maximum 30 percent evaluation. Id. In rating cranial or peripheral nerve disability, neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123 (2012). After thorough consideration of the evidence of record, the Board concludes that the preponderance of the evidence is against the assignment of an evaluation greater than 20 percent for the Veteran's residuals of a biopsy, granulomatous, buccal sulcus, on the right side of the mouth. The Veteran was afforded a VA oral and dental examination in April 2012, at which time it was noted that he developed signs and symptoms of right infraorbital nerve dysesthesia and right buccal branch facial nerve weakness after undergoing maxillary tooth number three extraction and hematoma evacuation from the right buccal space in 1971. Upon physical examination, there was a 3-centimere intraoral scar on the maxillary vestibule. The Veteran also exhibited painful dysesthesia to nociceptive stimuli throughout the right maxillary nerve distribution as well as weakness of the buccal branch of the right facial nerve effective buccinator and upper lip movement approximately 50 percent. Examination also revealed static and dynamic facial asymmetry of the right upper lip / cheek area from a decrease in motor activity of the right buccal branch of the seventh cranial nerve. However, there was no functional impairment due to loss of motion and masticatory function loss. Interincisal range of motion was limited from zero to 40 millimeters, and lateral excursion was to 11 millimeters. The Veteran was diagnosed as having painful dysesthesia of right maxillary nerve distribution, 50 percent decreased motor activity of the right buccal branch of the seventh cranial nerve affecting the cheek and upper lip, and a 3-centiemeter scar on the maxillary vestibule. Accordingly, the Board concludes that the Veteran's residuals of a biopsy, granulomatous, buccal sulcus, on the right side of the mouth do not more closely resemble complete paralysis of the fifth (facial) cranial nerve. 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8307. The main manifestations of the residuals were painful dysesthesia to nociceptive stimuli throughout the right maxillary nerve distribution as well as weakness of the buccal branch of the right facial nerve effective buccinator and upper lip movement approximately 50 percent which resulted in static and dynamic facial asymmetry of the right lip / upper cheek area. Significantly, there was no functional impairment due to loss of motion, nor was there any evidence of complete paralysis. In sum, the more probative evidence establishes that there is sensory impairment that results in no more than incomplete, severe neuropathy. Consideration has also been given to whether an increased rating for residuals of a biopsy, granulomatous, buccal sulcus, on the right side is warranted under other potentially applicable diagnostic codes pertaining to diseases of the cranial nerves. Schafrath, 1 Vet. App. at 595. However, the Board finds no basis upon which to assign a higher evaluation than 20 percent to the Veteran's disability, as the Veteran's symptomatology does not indicate that any other cranial nerve was implicated by his disability. Specifically, there is no evidence of neuritis, neuralgia, or paralysis of any of the other cranial nerves. 38 C.F.R. § 4.124a, Diagnostic Codes 8205-8412. Accordingly, an increased evaluation is not warranted under any other diagnostic code pertaining to the cranial nerves. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical"). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Veteran's residuals of a biopsy, granulomatous, buccal sulcus, on the right side are evaluated as neuritis of the seventh (facial) cranial nerve under 38 C.F.R. § 4.124a, Diagnostic Code 8307. The criteria of that diagnostic code are found by the Board to specifically contemplate the level of disability and symptomatology manifested by the Veteran's residuals of a biopsy, granulomatous, buccal sulcus, on the right side. As noted above, the Veteran's residuals are manifested by painful dysesthesias and weakness of the seventh (facial) cranial nerve, without functional impairment. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the evaluations assigned. Ratings in excess of those assigned are provided for certain manifestations of the Veteran's residuals, but the medical evidence of record does not demonstrate that such manifestations were present in this case. The criteria for the disability rating assigned more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluations are adequate and no referral is required. After review of the evidence of record, there is no evidence of record that would warrant a rating in excess of those assigned for the Veteran's service-connected disorder at any time during the period pertinent to this appeal. 38 U.S.C.A. 5110 (West 2002); see also Hart, 21 Vet. App. at 509. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Service Connection Claims Service connection will be awarded for disability resulting from injury or disease incurred in or aggravated by active service (wartime or peacetime). 38 U.S.C.A. §§ 1110; 1131 (West 2002), 38 C.F.R. § 3.303(a) (2012). Service connection requires competent evidence showing: (1) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; (2) medical evidence of current disability; and (3) medical evidence of a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). In Caluza, the Court also stressed that § 3.102 states, "The reasonable doubt doctrine is also applicable even in the absence of official records, particularly if the basic incident arose under combat, or similarly stressful conditions, and is consistent with the probable results of such known hardships." Caluza, 7 Vet. App. at 509. Each disabling condition shown by service medical records, or for which the Veteran seeks 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. 38 C.F.R. § 3.303(a). "Direct" service connection may be granted for any disease not diagnosed initially until after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Chronic diseases listed at 38 C.F.R. §§ 3.307, 3.309 are accorded special consideration for service connection. Where a Veteran served at least 90 days during a period of war or after December 31, 1946, and a listed chronic disease, such as primary anemia, becomes manifest to a degree of 10 percent within one year from the date of termination of such service, such disease will be presumed to have been incurred in service, even though there is no evidence of such disease during service. 38 U.S.C.A. §§ 1101, 1113, 1137 (West 2002); 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Once the evidence has been assembled, the Board assesses the credibility and weight to be given to the evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) and cases cited therein. When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that a Veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Arteriosclerotic Vascular Disease In September 2009, the Veteran filed a claim for entitlement to service connection for coronary artery disease / arteriosclerotic vascular disease. However, service connection presupposes a current diagnosis of the claimed disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The U.S. Court of Appeals for Veterans Claims (Court) has held that the "current disability" requirement is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary's adjudication of the claim." See McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, there is no evidence that the Veteran has coronary artery disease or arteriosclerotic vascular disease, currently or at any time during the pendency of this claim. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) (holding that pain alone without a diagnosed or identifiable underlying malady or condition did not constitute a disability for which service connection may be granted). Even when the claim is construed broadly, there is no evidence of a current cardiac disease warranting entitlement to service connection. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran's VA treatment records do not reveal diagnosis of or treatment for coronary artery disease or arteriosclerotic vascular disease. Rather, the Veteran's active problem lists included atypical chest pain, hypertension, and hyperlipidemia. He was prescribed aspirin and pravastatin. Private treatment records show diagnosis of peripheral vascular disease with no evidence of cardiopulmonary disease. A private echocardiogram performed in May 2012 was within normal limits. The Veteran was afforded a VA heart examination in March 2012, at which time the examiner found that there was no documentary evidence to establish a diagnosis of ischemic heart disease, noting that the Veteran had a normal dobutamine stress echocardiogram in 2010. This finding was confirmed in an August 2012 addendum written following a review of the Veteran's claims file. Therefore, without a current diagnosis of coronary artery disease or arteriosclerotic vascular disease, service connection cannot be warranted. The Veteran has been afforded ample opportunity to present competent medical evidence which includes a diagnosis of coronary artery disease or arteriosclerotic vascular disease. He has not done so. See 38 U.S.C.A. § 5107(a) (West 2002) (it is a claimant's responsibility to support a claim of entitlement to VA benefits). It is well established that laypersons without medical training, such as the Veteran, are not competent to comment on medical matters such as diagnosis of a disability like heart disease. Cf. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Accordingly, the Board has placed greater probative weight on the conclusions of the physicians who have provided treatment for and conducted examinations of the Veteran, because such conclusions and findings were made by medical professionals who are competent to render opinions regarding medical matters. Because the Veteran has not been shown to have the claimed disability, a preponderance of the evidence is against the Veteran's claim for service connection for coronary artery disease or arteriosclerotic vascular disease. The benefit-of-the-doubt rule does not apply, and service connection is not warranted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Low Back Disorder The Veteran also seeks entitlement to service connection for a low back disorder. Specifically, he has alleged that he sustained an in-service low back injury during an physical altercation with military police that was documented in his service treatment records in September 1971. Service treatment records reveal a single instance of complaints of and treatment for low back pain. A treatment note dated in November 1971 indicated that the Veteran was discharged from the physical therapy clinic, where low back pain was treated from October 28, 1971, to November 3, 1971, with ice massages and Williams flexion exercises. There are no other subsequent records of low back symptomatology in the service treatment records. This suggests that the low back symptomatology noted in November 1971 was acute and transitory rather than chronic in nature. The Board emphasizes that following the September 1971 physical altercation with military police documented in the service treatment records, the Veteran only reported injuries to the left eye, right arm, and head. However, post-service treatment records suggest that the Veteran sustained a serious back injury shortly after separation from service in January 1973. For instance, a March 1998 private treatment note indicated that the Veteran broke his back as a result of lifting a patient while working as a registered nurse at St. Joseph's Hospital in Fort Worth, Texas, in 1973. The Veteran also indicated that he reinjured his back in 1993. VA treatment records reveal treatment for chronic back pain, which is listed among his active problems. The Veteran was afforded a VA orthopedic examination in March 2012, at which time he was diagnosed as having chronic lumbar degenerative disc disease with recurrent herniated nucleus pulposus. At that time, the Veteran reported having a lifting injury in 1973 which was treated at the time with medications, and undergoing a subsequent laminectomy of L5 due to chronic lumbar pain in February 1974. The Veteran further reported undergoing a second laminectomy in 1994, and being unable to work due to back pain since that time. In an addendum opinion dated in August 2012, the VA examiner opined that it was less likely as not that the Veteran's current lumbar condition was caused by, aggravated by, or the result of active duty service. The examiner emphasized that the service treatment records noted only a single incidence of low back pain in 1971, with no recurrent or chronic conditions found through his separation from service in January 1973. The examiner explained that no evidence of degenerative disc disease of the spine, or chronic or recurrent lumbar conditions, were found in the service treatment records. Based on a review of the foregoing the Board finds that service connection is not warranted for a back disorder. The lone instance of lumbar complaints treated in service was shown to be for complaints of pain. There was no history of trauma, no actual back disability diagnosed, and no subsequent medical evidence of back problems in service. Likewise, there is no evidence on file supporting the contention that the Veteran's current back disorder began during a period of service ending in January 1973. To the contrary, the evidence strongly suggests, and the Veteran has conceded on several occasions, that his current back disorder had its onset subsequent to his separation from service when he broke his back while trying to lift a patient in his capacity as a registered nurse. The Veteran, as a lay person, is competent to report as to the nature, severity and frequency of his symptoms. However, he is not shown to be competent to provide a medical nexus opinion or medical diagnosis. As far as any contention of continuity of symptoms from service, his credibility is adversely affected his own admission that his back problems began as a result of an injury sustained as a registered nurse following his separation from service. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-7 (Fed. Cir. 2006) (holding the Board is obligated to, and fully justified in, determining whether lay testimony is credible in and of itself, and that the Board may weigh the absence of contemporary medical evidence against lay statements). The preponderance of the evidence is against the Veteran's claim for service connection. Accordingly, the claim must be denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine of 38 U.S.C.A. § 5107(b) is inapplicable here. ORDER An evaluation in excess of 20 percent for residuals of a biopsy, granulomatous, buccal sulcus, on the right side of the mouth is denied. Service connection for arteriosclerotic vascular disease, claimed as secondary to an acquired psychiatric disorder, is denied. Service connection for a low back disorder is denied. REMAND As discussed above, the Veteran also seeks entitlement to an initial compensable evaluation for an inability to wear a partial bridge due to excisional biopsy. He was afforded a VA examination in April 2001, at which time the examiner, a medical doctor, recorded a finding that upon examination of the right upper buccal surface of the Veteran's mouth, there was a small bony spur over the buccal surface of the right upper gingival ridge approximately a millimeter in diameter. The examiner stated that this was tender and would render the Veteran unable to wear a denture. At a February 2006 VA examination, the examiner recorded findings that neurological testing revealed right infraorbital nerve distribution to be 50 percent anesthetic; that there was a painful dysesthetic component to the nerve injury; that the right buccal branch VII was weak to moderate incomplete; and that the painful dysesthesia of the right infraorbital nerve precluded removable prostheses. In April 2006, following the February 2006 VA examination, the RO contacted that examiner (a doctor of dental surgery and staff oral surgeon at VA), and asked that examiner to provide an opinion as to whether or not the masticatory surface could be replaced by a prosthesis. In response, in an April 2006 addendum to the February 2006 VA examination, the examiner opined that, on review of the Veteran's panoramic radiograph and the February 2006 examination, a removable partial denture would adequately replace the masticatory surface of the Veteran's partially edentulous maxilla. Based on this evidence, the Board denied the Veteran's claim for an increased rating in a February 2007 decision. However, the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court), which determined that in its decision the Board failed to address or reconcile the apparent conflict between the two similar opinions contained in VA examinations of April 2001 and February 2006 VA, and the later April 2006 addendum to the February 2006 examination report. As such, the Court vacated and remanded the issue to the Board for further development consistent with its decision. In June 2009, pursuant to the Court's orders, the Board remanded the case in order to arrange for a review of the claims file by the VA examiner who examined the Veteran in February 2006 for his dental/oral condition and provided the April 2006 addendum to that examination. Specifically, that VA examiner was asked to provide an opinion to clarify and/or reconcile the apparent conflict between (1) the two consistent opinions found in the April 2001 and February 2006 examination reports, respectively, that the dental/oral condition would render the veteran unable to wear a denture, and that the painful dysesthesia of the right infraorbital nerve precluded removable prostheses; and (2) the conflicting opinion contained in the April 2006 addendum, that a removable partial denture would adequately replace the masticatory surface of the veteran's partially edentulous maxilla. In addition, the examiner was asked to provide an opinion as to which of the following two conditions result from the Veteran's service-connected residuals, excisional biopsy, granulomatous, buccal sulcus, right side of mouth: (i) teeth loss for which the loss of masticatory surface can be restored by suitable prosthesis; or (ii) teeth loss for which the lost masticatory surface cannot be restored by suitable prosthesis; and if so, which teeth are so involved. Pursuant to the Board's remand instructions, the VA examiner who conducted the February 2006 examination issued an addendum opinion in January 2010. At the outset, however, the examiner qualified himself as a oral and maxillofacial surgeon rather than a prosthodontist, subtly suggesting that a prosthodontist would be more qualified to answer the specific inquiries posed in the Board's June 2009 remand. He then simply explained that his previous conclusion that a painful dysesthesia precluded the use of removable partial dentures was based upon his understanding of neuropathic/dysesthetic pain and removable partial denture use. The January 2010 VA addendum opinion clearly failed to adequately answer all of the inquiries posed by the Board in its June 2009 remand. The examiner, by his own admission, was a oral and maxillofacial surgeon who was perhaps not equipped with the specialized knowledge to answer such questions. Nonetheless, in light of the noncompliance with the Board's prior remand directives, the Board finds the January 2010 VA addendum opinion to be inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Stegall v. West, 11 Vet. App. 268 (1998). As such, a new examination is required. The Veteran also seeks entitlement to service connection for a pyloric obstruction, peptic ulcer disease, headaches, and hypertension. Significantly, the Veteran has claimed that all of these disorders developed secondary to or were aggravated by his psychiatric disorder. The Veteran is currently service-connected for nightmare disorder, which has been assigned a 30 percent disability evaluation. Alternatively, the Veteran has indicated that these disabilities are adversely affected by all of his other service-connected disabilities. In addition to nightmare disorder, the Veteran is service connected for residuals of a biopsy, granulomatous, buccal sulcus, on the right side of the mouth; residuals of a right thumb fracture; residuals of a right little finger fracture; and an inability to wear a partial bridge. Examinations for pyloric obstruction, peptic ulcer disease, headaches, and hypertension were conducted in March through May 2012, and addendum opinions were obtained in August 2012. These opinions indicated that pyloric obstruction, peptic ulcer disease, headaches, and hypertension were unlikely related to the Veteran's military service, and unlikely secondary to his service-connected nightmare disorder. However, these opinions failed to address the likelihood that these disabilities were aggravated by the Veteran's service-connected nightmare disorder, as well as the likelihood that they were caused or aggravated by any of his other service-connected disabilities. Given the foregoing, the Board finds the VA opinions with respect to pyloric obstruction, peptic ulcer disease, headaches, and hypertension to be inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Stegall v. West, 11 Vet. App. 268 (1998). As such, new examinations are required. In addition, the Veteran seeks entitlement to service connected for a wrist disorder and an ankle disorder. Specifically, the Veteran claims that his wrist and ankle were injured during a physical altercation with military police in September 1971. Service treatment records confirm that the Veteran sought treatment for injuries following an altercation with military police in September 1971, at which time he was treated for an injury of the right arm/hand. He was outfitted with a forearm cast with a splint to the fifth digit. The Board also emphasizes that the Veteran is also currently service connected for residuals of a right thumb fracture and right little finger fracture. However, although the Veteran has been afforded VA orthopedic examinations for his spine and right hand/fingers, these examinations have not focused on the nature and probable etiology of his wrist and ankle symptomatology, if any. A medical examination and opinion addressing these matters are necessary prior to deciding the claims. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4). Finally, the Veteran seeks entitlement to a TDIU. However, the Board finds that the Veteran's claim for a TDIU is impacted by the increased evaluation and service connection claims and, therefore, is inextricably intertwined with these claims. The TDIU claim cannot be reviewed while the pending claims for increased ratings and service connection remain unresolved. As these issues are "inextricably intertwined," the TDIU claim needs to be remanded pending adjudication of the Veteran's remaining claims. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (all issues "inextricably intertwined" with an issue certified for appeal must be identified and fully developed prior to appellate review). Accordingly, the case is REMANDED for the following action: 1. Arrange for a review of the claims file by an appropriate VA examiner with adequate training in the field of prosthetic dentistry. The examiner should review the claims file, and if deemed necessary to answer the questions below, arrange for examination of the Veteran's service-connected dental/oral condition affecting the ability to restore lost masticatory surface by suitable prosthesis. The examiner should particularly review and comment on opinions contained in the reports of VA examinations of April 2001 and February 2006, and contained in an April 2006 addendum to the February 2006 examination. After the review, The examiner should provide an opinion to clarify and/or reconcile the apparent conflict between (1) the two consistent opinions found in the April 2001 and February 2006 examination reports, respectively, that the dental/oral condition would render the veteran unable to wear a denture, and that the painful dysesthesia of the right infraorbital nerve precluded removable prostheses; and (2) the conflicting opinion contained in the April 2006 addendum, that a removable partial denture would adequately replace the masticatory surface of the veteran's partially edentulous maxilla. The examiner should also provide an opinion as to which of the following two conditions result from the Veteran's service-connected residuals, excisional biopsy, granulomatous, buccal sulcus, right side of mouth: (i) teeth loss for which the loss of masticatory surface can be restored by suitable prosthesis; or (ii) teeth loss for which the lost masticatory surface cannot be restored by suitable prosthesis; and if so, which teeth are so involved. 2. Arrange for a review of the claims file by the VA examiners who examined the Veteran in 2012 for his pyloric obstruction, peptic ulcer disease, headaches, and hypertension. The examiners are asked to opine as to whether it is at least as likely as not (i.e., probability of 50 percent or greater) that these disabilities are caused or aggravated (worsened) by any of the Veteran's service-connected disabilities. 3. Schedule the Veteran for a VA orthopedic examination of his wrist and ankle. Request that the examiner review the claims file and note review of the claims file including the in-service treatment rendered following the Veteran's altercation with military police in September 1971. Request that the examiner diagnose any current disabilities of the wrist and/or ankle. For any disability diagnosed, provide an opinion as to whether the disability is at least as likely as not (50 percent or greater possibility) related to the any incident in service, to include the September 1971 treatment, or whether it is related to or aggravated by any service-connected disability, to include residuals of right thumb and right little finger fractures. 4. Review the claims file to ensure that all the foregoing requested development is completed, and arrange for any additional development indicated. Then, readjudicate the claims on appeal. If any benefit sought remains denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative the requisite time period to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. 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). 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). ______________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs