Citation Nr: 1330153 Decision Date: 09/20/13 Archive Date: 09/25/13 DOCKET NO. 09-35 514 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for prostate cancer, to include as due to herbicide exposure. 2. Entitlement to service connection for colon cancer, to include as due to herbicide exposure and as secondary to prostate cancer. 3. Entitlement to service connection for hypertension, to include as due to herbicide exposure. 4. Entitlement to service connection for degenerative joint disease of the neck. 5. Entitlement to service connection for degenerative joint disease of the back. 6. Entitlement to an initial disability rating (evaluation) in excess of 0 percent for bilateral hearing loss prior to April 7, 2011 and in excess of 10 percent thereafter. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARINGS ON APPEAL Appellant (Veteran) ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from August 1947 to February 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2007, June 2009, and March 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The Board has reviewed the Veteran's physical claims file, as well as the electronic file on the "Virtual VA" system, to ensure a complete review of the record in this case. In July 2009, the Veteran presented testimony relevant to the appeal at a hearing before a Decision Review Officer at the RO. Also, in July 2013, the Veteran presented testimony relevant to the appeal at a Board hearing held in Washington, DC before the undersigned Veterans Law Judge (VLJ). The hearing transcripts are of record. At the Board hearing, the Veteran clarified that he was seeking service connection for degenerative joint disease of the neck and back. In consideration thereof, the Board has recharacterized the issue as stated on the first page of the decision (i.e., service connection for degenerative joint disease of the neck and back). Due to the Veteran's advanced age, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of: (1) service connection for colon cancer, to include as due to herbicide exposure and as secondary to prostate cancer; and (2) service connection for degenerative joint disease of the neck and back 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 engaged in combat with the enemy during service. 2. The Veteran was exposed to herbicide agents during service in Thailand. 3. The Veteran was diagnosed with and began treatment for prostate cancer in 1999. 4. Prostate cancer is a disease associated with herbicide exposure. 5. The Veteran's prostate cancer is presumed to be due to exposure to herbicide agents during active service. 6. There was no injury or disease of the cardiovascular system or chronic symptoms of hypertension in service. 7. Hypertension did not manifest to a compensable degree within one year of service. 8. Symptoms of hypertension have not been continuous since separation from service. 9. The Veteran's current hypertension is not causally or etiologically related to active service, to include any incident or event therein such as herbicide exposure. 10. For the portion of the rating period prior to April 7, 2011, the evidence demonstrated a Level II hearing acuity in the service-connected right ear and more nearly approximated a Level V hearing acuity in the service-connected left ear. 11. During the portion of the rating period from April 7, 2011, forward, the evidence demonstrated no worse than a Level II hearing acuity in the service-connected right ear, and a Level V hearing acuity in the service-connected left ear. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, prostate cancer is presumed to have been incurred during active military service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 2. Hypertension was not incurred in active military service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 3. Giving the benefit of the doubt to the Veteran, the criteria for an initial disability rating of 10 percent for bilateral hearing loss have been approximated for the portion of the rating period prior to April 7, 2011. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.85, Diagnostic Code (DC) 6100 (2013). 4. The criteria for an initial disability rating in excess of 10 percent for bilateral hearing loss have not been met or more nearly approximated for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.85, DC 6100 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 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 of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA 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). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a statement of the case (SOC) or supplemental statement of the case (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Due to the favorable outcome of the Veteran's appeal for service connection of prostate cancer, which is the full grant of the benefits sought, the claim has been substantiated, obviating the need for discussion of how VA fulfilled the duties to notify and assist for that issue. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Regarding the Veteran's claimed bilateral hearing loss, the Veteran is challenging the initial disability ratings (i.e., the staged rating) assigned following the grant of service connection for bilateral hearing loss in the August 2007 rating decision. The U.S. Court of Appeals for Veterans Claims (Court) has held that, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has in fact been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess v. Nicholson, 19 Vet. App. 473, 490-91; Dunlap v. Nicholson, 21 Vet. App. 112, 117 (2007). Furthermore, under 38 C.F.R. § 3.159(b)(3)(i), there was no duty to provide the Veteran with VCAA notice upon receipt of a Notice of Disagreement, such as in this case. For these reasons, the Board finds that no further notice, beyond that afforded in the context of the claim for service connection, is needed under the VCAA. In a February 2007 notice letter sent prior to the initial denial of the claim for service connection for hypertension, the RO apprised the Veteran of the information and evidence necessary to substantiate the service connection claim, which information and evidence that he was to provide, and which information and evidence that VA would attempt to obtain on his behalf. In this regard, the RO advised the Veteran of what the evidence must show to establish entitlement to service-connected compensation benefits, and described the types of information and evidence that the Veteran needed to submit to substantiate the claim. The RO also explained what evidence VA would obtain and make reasonable efforts to obtain on the Veteran's behalf in support of the claim. The RO further informed the Veteran how VA determines the disability rating and effective date once service connection is established, which satisfied Dingess notice requirements. In consideration of the foregoing, the Board finds that the VCAA notice requirements were fully satisfied prior to the initial denial of the claim, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Regarding VA's duty to assist in claims development, the RO afforded the Veteran with medical examinations in connection with the initial rating appeal for bilateral hearing loss in August 2007 and April 2011. The medical examination reports include all relevant findings and medical opinions needed to evaluate fairly the Veteran's initial rating appeal. The medical examiners took a thorough history of the bilateral hearing loss disability from the Veteran, including history of onset, diagnosis, report of symptomatology, other limitations, and treatment. An adequate description of the functional effects of the Veteran's hearing loss was noted. Martinak v. Nicholson, 21 Vet. App. 447 (2007). The medical examiners had adequate facts and data regarding the history and condition of the disability. See VAOPGCPREC 20-95 (interpreting that in some cases an accurate history by a veteran may be a valid basis for an examination report rather than claims file review); see also Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). For these reasons, the Board finds that the medical examination reports are adequate for rating purposes, and there is no need for further VA audiological examination. The Board has considered the representative's argument that the Veteran should be provided with a more contemporaneous VA audiological examination because the April 2011 audiological examination is over two years old and showed a sharp increase since the prior VA audiological examination in October 2005. The representative noted that the increase showed the instability of the Veteran's hearing loss, and a more current VA audiological examination should show the current level of severity of the disability. However, the Board finds that another VA audiological examination is not needed. The VA treatment records included in the Virtual VA folder contain audiometric data from June 2012, which is during this later period, and the Board has considered the findings in the analysis of the initial rating appeal. The June 2012 VA audiometric findings do not show worsened hearing loss disability. Neither the Veteran nor the representative has indicated that the hearing loss disability has worsened since June 2012. Palczewski v. Nicholson, 21 Vet. App. 174, 180 (2007). For these reasons, no further VA audiological examination is warranted. Regarding claimed hypertension, the Board notes that the Veteran was neither provided with a VA medical examination nor a VA medical opinion in connection with the appeal. However, after review of the record, the Board finds that no such development is needed. The Veteran's assertion at the Board hearing that he was diagnosed with, and treated for, hypertension during active service is inconsistent with, and outweighed by, other evidence, to include his own statements at service separation, and is not deemed credible. Additionally, there is no competent evidence showing that hypertension is causally or etiologically related to the Veteran's period of active military service, to include presumed herbicide exposure. The weight of the evidence is against finding in-service injury or disease relevant to the claimed disability of hypertension. The evidence also shows no continuous symptoms of hypertension since service or that hypertension manifested to a compensable degree within one year of service separation. Although, for reasons explained below, the Board finds that the Veteran was exposed to herbicide agents, hypertension is not included among the diseases associated with herbicide exposure under 38 C.F.R. § 3.309(e), and the Veteran has not presented competent evidence of a nexus between hypertension and herbicide exposure. As no medical examination or medical opinion would help substantiate the Veteran's claim, the Board does not find that any such development is necessary. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (where the Board makes a finding that lay evidence regarding an in-service event or injury is not credible, a VA examination is not required). Also, the Board notes that the Veteran's complete service treatment records are in the claims file. Post-service treatment records adequately identified as relevant to the claims decided herein have been obtained, or otherwise submitted, and are associated with the record. Additional pertinent treatment records found in the Virtual VA folder were considered by the RO in the first instance. The Veteran has also submitted several lay statements in support of the appeal, as well as offered testimony before the DRO and the Board in connection with the appeal. Notably, the Veteran has reported that he is not in receipt of Social Security disability benefits (see February 2007 VA Form 21-4138), and the February 2007 response to the request for records from the Social Security Administration (SSA) was negative. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who conducts 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. At the July 2013 Board hearing, the undersigned VLJ identified the issues on appeal, including specific theories of service connection for the issues (direct, herbicide exposure, secondary), and elicited testimony as to when symptoms and treatment of the disabilities allegedly began. The VLJ also posed several questions of the Veteran during the course of the Board hearing to clarify the contentions and to ascertain whether there was additional evidence pertinent to the appeal that needed to be obtained. At the Board hearing, through the representative, the Veteran demonstrated understanding of the evidence required to substantiate the claims of service connection, as well as the initial rating appeal. See Board hearing transcript, page 21 (wherein the representative referenced the 3-part test for service connection and the fact that the level of severity was pertinent to the initial rating claim); see also Dalton v. Nicholson, 21 Vet. App. 23, 30 (2007) (Court was convinced that appellant had demonstrated actual knowledge of the information and evidence necessary to establish the claim). In consideration thereof, the Board finds that the duties under 38 C.F.R. § 3.103(c)(2) were satisfied. Given the foregoing, the Board concludes that the Veteran has been provided with proper notice and all relevant facts have been properly and sufficiently developed in this appeal. No further notice or development is required. Therefore, the Board will proceed with appellate review. It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). The Board has thoroughly reviewed all the evidence in this case. The analysis below focuses on the most relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). Service Connection Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Veteran is currently diagnosed with hypertension, which is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are applicable with respect to that diagnosis. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). In addition, the law provides that, where a veteran served ninety days or more of active service, and certain chronic diseases, such as hypertension and malignant tumors, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. In order to establish presumptive service connection for a disease associated with exposure to certain herbicide agents, a veteran must show the following: (1) that he served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 (or was otherwise exposed to an herbicide agent during active service); (2) that he currently suffers from a disease associated with exposure to certain herbicide agents enumerated under 38 C.F.R. § 3.309(e); and (3) that the current disease process manifested to a degree of 10 percent or more within the specified time period prescribed in section 3.307(a)(6)(ii). 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). If a veteran was exposed to a herbicide agent during active military, naval, or air service, the certain diseases shall be service-connected, if the requirements of 38 C.F.R. § 3.307(a) are met, even if there is no record of such disease during service. The list of diseases associated with exposure to certain herbicide agents includes prostate cancer. See 38 C.F.R. § 3.309(e). During the pendency of this appeal, on August 31, 2010, the Secretary published a final rule in the Federal Register amending 38 C.F.R. § 3.309(e). See 75 Fed. Reg. 53,202. The final rule was effective August 31, 2010. Specifically, VA amended 38 C.F.R. § 3.309(e) to add hairy cell leukemia and other chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina) to the list of diseases associated with exposure to certain herbicide agents. Note 3 at the end of § 3.309 states that: "for purposes of this section, the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease." Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. A veteran is competent to describe symptoms that he or she experienced in service or at any time after service when the symptoms he or she perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (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, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F. 3d at 1377. Also, a veteran as a layman is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layman is competent to identify the medical condition; he is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). In this case, the Veteran was part of the Vietnam Air Campaign from April 1966 to June 1966, the Vietnam Air Offensive Campaign from June 1966 to March 1967, and had "counterinsurgency experience" from April 1966 to April 1967 while stationed in Thailand; therefore, despite the absence of any medals or military citations clearly denoting combat service, the Board finds that the Veteran had combat service. However, both prostate cancer and hypertension are disease entities and are neither the result of combat injury nor the types of diseases that result from the conditions, hardships, or circumstances of combat service. Therefore, the presumption afforded combat veterans under 38 U.S.C.A. § 1154(b) is not applicable in this case. Service Connection for Prostate Cancer Analysis At the Board hearing, the Veteran testified that he served in Thailand from April 1966 to April 1967 and from April 1969 to April 1970. He reported that, during both periods of Thailand service, he lived off base but rode a bus or drove a car on a daily basis to and from the Udorn Air Force Base (AFB) and Takhli AFB, respectively, in order to perform his duties in supply such as ordering and delivering various supplies and routinely crossed the perimeter of the air bases. The majority of troops in Thailand during the Vietnam Era were stationed at the Royal Thai Air Force Bases of U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang. If a veteran served on one of these air bases as a security policeman, security patrol dog handler, member of a security police squadron, or otherwise served near the air base perimeter, as shown by MOS (military occupational specialty), performance evaluations, or other credible evidence, then herbicide exposure should be acknowledged on a facts-found or direct basis. However, this applies only during the Vietnam Era, from February 28, 1961, to May 7, 1975. See M21-1MR, Part IV, Subpart ii, Chapter 2, Section C.10.(q). In this case, the service personnel records show that, prior to his deployment to Thailand in April 1966, the Veteran underwent an "isolated duty" examination in February 1966. The service personnel records also show that the Veteran was stationed in an "isolated area" of Thailand from April 1966 to April 1967 and from April 1969 to April 1970, and served as an inventory management supervisor in the Air Force during the service periods. Also, as noted by the representative at the Board hearing, the Veteran's service treatment records reflect medical treatment for flu-like syndrome at Udorn AFB in January 1967 and for rash at Takhli AFB in April 1969. As noted above, the Veteran testified at the Board hearing that he lived off base and rode a bus or car on a daily basis to and from the Udorn AFB and the Takhli AFB during his Thailand service. The service personnel records provide support for the Veteran's hearing testimony because they show that he was assigned to an "isolated area" while serving in Thailand, which is consistent with his testimony that he lived downtown and away from the air base. Also, the Board finds it likely that the Veteran would seek medical attention for medical illness at the air base where he was routinely performing his duties; therefore, the fact that the Veteran's service treatment records show treatment at Udorn AFB and Takhli AFB provides support for the Veteran's testimony that he daily performed his duties as a supply manager at those air bases while stationed in Thailand. Furthermore, the Veteran reported at the Board hearing that he crossed the perimeter of the bases on a daily basis for a total of two years (i.e., two separate periods of Thailand service) while performing his duties as a supply manager, which included both ordering and transporting the necessary supplies for the air bases. The Veteran's hearing testimony that performing his duties in supply required daily commute to and from the air base, as well as the transport of supplies to and from the air base, is consistent with the circumstances and conditions of the Veteran's service and is credible evidence of service near the air base perimeter. For these reasons, resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran was exposed to herbicide agents during service; therefore, the Board concludes that the Veteran is entitled to presumptions based on herbicide exposure. See 38 C.F.R. §§ 3.307, 3.309. The record establishes that the Veteran was first diagnosed with and treated for prostate cancer in 1999. Specifically, a November 1999 private treatment record includes an impression of a well to moderately differentiated Stage T2B adenocarcinoma of the prostate. Because prostate cancer is a disease presumptively associated with herbicide exposure and the Board has found, based on the facts presented in this case, that the Veteran was exposed to herbicide agents during his Thailand service, service connection for prostate cancer is granted on a presumptive basis as due to herbicide exposure. In granting the Veteran's appeal for service connection for prostate cancer, the Board notes that the Veteran possibly may have been entitled to service connection on the bases that chronic symptoms of prostate cancer manifested in service, continuous symptoms of prostate cancer have manifested since service, and/or prostate cancer manifested to a compensable degree within one year of service; however, because the appeal is granted based on presumptive service connection of prostate cancer due to the in-service herbicide exposure found in this case, analysis of entitlement to service connection for prostate cancer under other potential theories of entitlement is not required. 38 U.S.C.A. § 7104 (no remaining questions of law or fact to decide). Service Connection for Hypertension Analysis At the Board hearing, the Veteran testified that he was diagnosed with, and treated for, hypertension in 1969, which was during active service. He alternatively contends that hypertension is related to herbicide exposure during service. See Board hearing transcript, pages 2-3. In this case, there is ample evidence of a current diagnosis of hypertension; therefore, the question of whether the Veteran has a current disability is not in dispute. See, e.g., April 2009 VA primary care physician note (including an assessment of hypertension). In consideration thereof, the Board will next consider whether current hypertension, to include symptoms related thereto, had its onset during active service or is otherwise causally or etiologically related to active service, to include herbicide exposure. "Hypertension" refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 mm Hg systolic and from 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic as reflective of hypertension. Dorland's Illustrated Medical Dictionary 909 (31st ed. 2007). Similarly, for VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater. The term "isolated systolic hypertension" means that the systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2013). After a review of all the evidence, both lay and medical, the Board finds that the weight of the evidence demonstrates that no vascular injury, disease, or symptoms of hypertension were manifested during service. Review of the Veteran's service treatment records shows that, while he was on active duty, his blood pressure readings were consistently within normal limits, to include at the August 1970 service retirement examination (i.e., 112/88). Also, on the August 1970 service retirement report of medical history, the Veteran checked "No" when asked if he then had or had ever had high or low blood pressure. Similarly, on the August 1970 Dental Patient History, the Veteran checked "No" when asked if he had ever been treated for high blood pressure, or various other health conditions. Earlier service reports of medical history also show that the Veteran checked "No" when asked if he then had or had ever had high or low blood pressure. See August 1956 and February 1966 service reports of medical history. The representative noted, at the Board hearing, that the Veteran's blood pressure readings during active service showed a gradual increase; however, as stated above, the blood pressure readings were consistently within normal limits and no blood pressure reading showing a diastolic pressure of 100 or more or a systolic pressure of 160 or more was manifested. Thus, blood pressure readings throughout service are within normal limits, to include at the August 1970 service retirement examination, and the Veteran's statements on the August 1970 service retirement report of medical history, as well as on earlier reports of medical history completed during service, weigh against finding that symptoms of hypertension began in service. The Veteran testified, at the Board hearing, that he was diagnosed with hypertension in 1969 during service; however, this account of diagnosis is inconsistent with the service treatment records, which are complete, and show no diagnosis or treatment for hypertension during service. See Board hearing transcript, pages 22- 24. It is also inconsistent with the service retirement examination in August 1970, which shows that the Veteran denied then having or ever having had high blood pressure. The service report of medical history is dated after the time that the Veteran testified that he was diagnosed with hypertension during service; thus, if the Veteran had been diagnosed with and treated for hypertension in 1969, as he now asserts, it is likely that he would have answered "Yes" when asked about then having hypertension when completing the form. The fact that the Veteran answered "No" during service and no hypertension was detected at the time of the August 1970 service retirement examination weighs against the credibility of his account of having been diagnosed with hypertension during service. After weighing the evidence, the Board finds the service treatment records, which include the Veteran's lay statements, to be more credible and of greater probative weight because they were generated during active service and are more likely to reflect accurately the Veteran's physical state at the time. The Veteran's testimony at the Board hearing, however, was provided many years after service retirement and is more likely to be compromised by an unreliable memory and to be influenced by the desire for pecuniary gain; therefore, the evidence does not show hypertension or chronic symptoms of hypertension during service. The Board next finds that the evidence shows that the Veteran did not continuously manifest symptoms of hypertension since service, including not to a degree of ten percent within one year of service separation. See 38 C.F.R. § 4.104, Diagnostic Code 7101. The earliest evidence of record reflecting the presence of hypertension is dated in November 1999, many years after service retirement. At that time, the Veteran told medical providers treating prostate cancer that he had a medical history of hypertension; however, he made no mention of having had hypertension during or ever since active service. Because the Veteran reported at the Board hearing that he was diagnosed with and treated for hypertension in 1969, and the account is inconsistent with the service medical evidence and history as explained above, the Veteran's account of hypertension having been diagnosed with hypertension during service is not credible. Similarly, the Veteran has not provided credible evidence that hypertension manifested to a compensable degree within the first post-service year. Rather, the earliest credible evidence of hypertension is not shown for many years after service. The absence of post-service complaints or findings of hypertension for many years after service is one factor that tends to weigh against a finding of hypertension in service or continuous symptoms after service retirement, to include to a compensable degree within the first post-service year. See Buchanan v. Nicholson, 451 F.3d 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor to consider as evidence against a claim of service). Also, during the Board hearing, the Veteran provided inconsistent accounts of when he began to take medication for treatment of hypertension. Initially, the Veteran stated that he had been on blood pressure medication for the last ten to fifteen years. See Board hearing transcript, page 22. However, he later stated that he was given medication during service to treat hypertension. See Board hearing transcript, page 24. In light of the inconsistent accounts provided by the Veteran at the Board hearing regarding when he started taking medication for hypertension, the service medical evidence showing no finding or treatment for hypertension and including the Veteran's denials of having high blood pressure during service, and the post-service medical evidence first showing hypertension many years after service, the Board does not find the Veteran's account of having been given medication for hypertension during service to be credible. Rather, the Board finds the Veteran's account of having been treated for hypertension with medication since approximately 1998 to be more credible and of greater probative value because it is more consistent with the evidence of record. The Board additionally notes that the Veteran has not provided credible evidence to show that hypertension began during the first post-service year. As stated above, the evidence shows that hypertension was not diagnosed and treated until many years after service. The evidence does not show manifestations of hypertension to a degree of ten percent within one year of service separation. Therefore, the Board finds that, because hypertension was not manifested to a degree of ten percent within one year of service separation, there is no basis for presumptive service connection. 38 C.F.R. §§ 3.307, 3.309. The Board further finds that the weight of the evidence demonstrates that hypertension, which first manifested many years after service, was not caused by any in-service incident or event, including herbicide exposure during service. As noted, hypertension is, by regulation, not a disease for which service connection may be presumed as being the result of herbicide exposure. The scientific studies reviewed as part of that regulatory process established no correlation between herbicide exposure and hypertension that developed many years later such that hypertension was specifically excluded by regulation as a disease associated with herbicide exposure. There is no competent evidence of record that has demonstrated a relationship between the current hypertension and active military service, to include in-service exposure to herbicide agents during service. The earliest evidence of hypertension is noted in a post-service November 1999 treatment record, and the Veteran testimony at the Board hearing that he began taking medication for hypertension approximately in 1998 is credible. This evidence of post-service treatment (i.e., medication) for hypertension beginning many years after service further weighs against the Veteran's claim. The record does not show vascular injury or vascular disease in service, symptoms of hypertension in service, or continuous symptoms of hypertension since service. As such there is no factual basis for the Board to seek a medical nexus opinion, or upon which a medical professional could relate the Veteran's hypertension to service, as any purported direct nexus opinion would be based on a factually inaccurate assumption of chronic and continuous symptoms and would be inconsistent with the scientific studies establishing the lack of such relationship. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative); see also Bardwell, 24 Vet. App. at 40. As such, direct service connection for hypertension is not established, and presumptive service connection for hypertension may not be established on a presumptive basis, including as due to herbicide exposure is not established. 38 C.F.R. §§ 3.307, 3.309. Although the Veteran has asserted that various events and/or incidents in active service caused his hypertension, he is a lay person and does not have the requisite medical expertise to render a competent medical opinion regarding the relationship between hypertension and active service. Such opinions as to causation involve making findings based on medical knowledge and clinical testing results, and the cardiovascular system is complex and involves unseen systems processes and disease processes that are not observable by the five senses of a lay person. Although the Veteran is competent to report having had high blood pressure readings, hypertension refers to persistently high arterial blood pressure, as stated above. Under VA regulation, hypertension is confirmed by readings taken two or more times on at least three different days reflecting diastolic blood pressure predominantly 90 mm or greater or systolic blood pressure predominantly 160 mm or greater with diastolic pressure less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Despite the Veteran's lay account that he has had high blood pressure since 1969, he has not presented credible evidence establishing that he had hypertension in service and there is no clinical documentation of hypertension until nearly three decades after service. Consequently, the Veteran's purported opinion relating hypertension to active service is of no probative value. Thus, in summary, the weight of the evidence demonstrates no vascular injury, vascular disease, or chronic symptoms of hypertension manifested in service; no symptoms of hypertension continuously manifested since service; hypertension was not manifested to a compensable degree within a year of service; and no nexus relationship between the Veteran's hypertension and service, to include presumed Agent Orange exposure. In consideration thereof, the Board finds that the preponderance of the evidence is against the claim, and service connection for hypertension must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Hearing Loss Disability Rating Legal Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In determining the disability rating, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of a veteran's condition. 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. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In a claim for a higher original rating after an initial award of service connection, all the evidence submitted in support of a veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. The Veteran's bilateral hearing loss disability has been initially rated noncompensable (0 percent) prior to April 7, 2011 and 10 percent for the period from April 7, 2011 under the rating criteria found at 38 C.F.R § 4.85, DC 6100. Hearing loss is evaluated under 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100, Tables VI, VIA, VII of VA's rating schedule. Upon review, the Board finds that no other diagnostic code or rating schedule would be appropriate in the evaluation of the Veteran's hearing loss disability. The Rating Schedule provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, established by a state-licensed audiologist including a controlled speech discrimination test (Maryland CNC), and based upon a combination of the percent of speech discrimination and the pure tone threshold average which is the sum of the pure tone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. 38 C.F.R. § 4.85. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz ) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VI A, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VI A, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. 38 C.F.R. § 4.86(b). Initial Rating Period prior to April 7, 2011 After review of the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether the severity of the Veteran's hearing loss disability warrants an initial 10 percent disability rating for the portion of the rating period prior to April 7, 2011. VA treatment records show that the Veteran presented for a VA audiology consultation with complaint of increased difficulty hearing in May 2006, which was approximately five months before filing the service connection claim for bilateral hearing loss. At the May 2006 VA audiology consultation, pure tone thresholds, in decibels, were recorded as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 20 50 60 LEFT 15 20 50 70 75 Pure tone threshold averages were 35 for the right ear and 54 for the left ear. Speech audiometry revealed speech recognition ability of 88 percent or better in the right ear and of 72 percent or better in the left ear. The Board will assume, for the purposes of the initial rating appeal, that the May 2006 treating VA audiologist was state-licensed and used a controlled speech discrimination test (Maryland CNC) as required by 38 C.F.R. § 4.85. Under the guidelines set forth in 38 C.F.R. § 4.85, the May 2006 audiometric results reveal that the Veteran, at worst, demonstrated Level II hearing acuity in the service-connected right ear (with a pure tone threshold average of 35 dB and speech discrimination score of 88 percent) and Level V hearing acuity in the service-connected left ear (with pure tone threshold average of 54 dB and speech discrimination score of 72 percent). According to Table VII under Diagnostic Code 6100 (with the left ear being the poorer ear and the right ear being the better ear), a 10 percent disability rating is warranted for the level of hearing impairment demonstrated at the time of the May 2006 VA audiology consult. 38 C.F.R. § 4.85. The Board notes that the May 2006 VA audiology consult occurred outside of the rating period (i.e., prior to October 30, 2006); however, the level of hearing loss disability demonstrated at that time is relevant to the initial rating appeal because the Veteran's hearing loss disability is to be viewed in relation to its history. See 38 C.F.R. § 4.1. See also 38 U.S.C.A. § 7104 (West 2002) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). In this case, the May 2006 VA audiology consultation treatment note, which noted the Veteran's chief complaint of increased hearing difficulty, reflected audiometric data pertaining to the severity of the Veteran's hearing loss disability approximately five months prior to his filing of the service connection claim for hearing loss. There is no indication in the record that there was a material change in the severity of the Veteran's hearing loss disability during the five-month period from the May 2006 VA audiology consult to the filing of the service connection claim in October 30, 2006. See, e.g., November 2006 VA emergency department note (noting the Veteran's denial of auditory changes). Therefore, resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for a disability rating of 10 percent were met for the Veteran's hearing loss disability for the portion of the rating period prior to April 7, 2011. The Board notes that the audiometric results of the April 2007 VA audiological examination show a noncompensable (i.e., 0 percent) level of hearing impairment. Indeed, at the April 2007 VA audiological examination performed in connection with the service connection claim, pure tone thresholds, in decibels, were recorded as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 30 50 55 LEFT 15 25 55 70 70 Pure tone threshold averages were 36 for the right ear and 55 for the left ear. Speech audiometry revealed speech recognition ability of 84 percent in the right ear and of 80 percent in the left ear. Under the guidelines set forth in 38 C.F.R. § 4.85, the audiometric results reveal that the Veteran demonstrated Level II hearing acuity in the service-connected right ear (with a pure tone threshold average of 36 dB and speech discrimination score of 84 percent) and a Level IV hearing acuity in the service-connected left ear (with pure tone threshold average of 55 dB and speech discrimination score of 80 percent). According to Table VII under Diagnostic Code 6100, the current noncompensable (i.e., 0 percent) disability rating is warranted for the level of hearing impairment demonstrated at the VA audiological examination. 38 C.F.R. § 4.85. Nevertheless, the audiometric results on VA audiological evaluations performed both before and after the August 2007 VA audiological examination show a level of hearing impairment that more closely approximates the criteria for a 10 percent schedular rating under DC 6100. Also, the Veteran's pure tone threshold average and speech discrimination score for the left ear at the August 2007 VA audiological examination, which yielded a Level IV hearing acuity for the left ear, were only slightly better than those recorded at the May 2006 VA audiology consultation, which demonstrated a Level V hearing acuity for the left ear. Indeed, at the August 2007 VA audiological examination, the evidence demonstrated a Level IV hearing acuity in the service-connected left ear based on a pure tone threshold average of 55 dB and a speech discrimination score of 80 percent; however, at the May 2006 VA audiological evaluation, the evidence demonstrated a Level V hearing acuity in the service-connected left ear based on a pure tone threshold average of 54 dB and a speech discrimination score of 72 percent. Thus, the difference between a demonstrated Level IV left ear hearing acuity and a Level V left ear hearing acuity is not significant in this case. In consideration of the foregoing, the Board finds that the evidence is in relative equipoise on the question of whether a Level V hearing acuity for the left ear is more representative of the level of hearing impairment for the left ear throughout the portion of the rating period prior to April 2011. For these reasons, the Board finds that the audiometric testing and speech recognition testing scores reflect that, for the portion of the rating period prior to April 7, 2011, the evidence demonstrated a Level II hearing acuity in the service-connected right ear and more nearly approximated a Level V hearing acuity in the service-connected left ear. In consideration thereof, and resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for a 10 percent schedular rating for bilateral hearing loss under DC 6100 have been approximated for the portion of the rating period prior to April 7, 2011. 38 C.F.R. §§ 4.3, 4.7. As it is only with the resolution of reasonable doubt that the criteria for a 10 percent rating for this period are met, the Board finds that a rating in excess of 10 percent is not met or more nearly approximated for this period. Initial Rating period from April 7, 2011 Forward After review of the lay and medical evidence of record, the Board also finds that the weight of the evidence is against finding that a disability rating for bilateral hearing loss in excess of 10 percent is warranted for the portion of the rating period from April 7, 2011, forward. At the April 2011 VA audiological examination performed in connection with the initial rating appeal, pure tone thresholds, in decibels, were recorded as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 40 55 60 LEFT 35 45 55 75 70 Pure tone threshold averages were 45 for the right ear and 61 for the left ear. Speech audiometry revealed speech recognition ability of 88 percent in the right ear and of 72 percent in the left ear. Under the guidelines set forth in 38 C.F.R. § 4.85, the audiometric results from the April 2011 VA audiological examination reveal Level II hearing acuity in the service-connected right ear (with a pure tone threshold average of 45 dB and speech discrimination score of 88 percent) and a Level V hearing acuity in the service-connected left ear (with pure tone threshold average of 61 dB and speech discrimination score of 72 percent). According to Table VII under Diagnostic Code 6100 (with the left ear being the poorer ear and the right ear being the better ear), a 10 percent disability rating, but no higher, is warranted for the level of hearing loss disability demonstrated at the VA audiological examination. 38 C.F.R. § 4.85. The VA treatment records for this portion of the rating period do not show that the Veteran's hearing loss disability meets or more nearly approximates the criteria for a disability rating greater than 10 percent. See the June 2012 VA audiology consultation note (indicating a Level II hearing acuity in the right ear and Level III hearing acuity in the left ear). In consideration of the foregoing, the Board finds that the severity of the Veteran's hearing loss disability is commensurate with a 10 percent disability rating, and no higher, for the portion of the rating period from April 7, 2011 forward. For these reasons, the Boar finds that the weight of the evidence is against finding that an initial rating for bilateral hearing loss in excess of the current 10 percent is warranted for any period of initial rating appeal, including the period from April 7, 2011 forward. In evaluating the initial rating appeal above, the Board notes that no exceptional pattern of hearing impairment was demonstrated for either ear at any evaluation performed during the rating period or at the May 2006 VA audiology consultation so as to warrant evaluation under Table VI or Table VIA. 38 C.F.R. § 4.86 (2013). Extraschedular Consideration for Initial Rating Appeal The Board has further considered whether the initial rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, it must be determined whether the disability picture is such that the schedular criteria are inadequate, i.e., whether there are manifestations or impairment that are not encompassed by the schedular criteria. If those criteria are not inadequate, the analysis does not need to proceed any further. In this case, the Board does not find any symptoms or functional impairment that is not already encompassed by the current 10 percent schedular rating for the entire rating period. The Veteran has generally reported that he has difficulty hearing and, more specifically, indicated that he had difficulty hearing on the telephone. See August 2007 and April 2011 VA audiological examination reports. Also, at the Board hearing, the Veteran testified that he often had to turn his hearing aids up to high in order to hear others. The Board notes that the decibel loss and speech discrimination ranges designated for each level of hearing impairment in Tables VI and VIA were chosen in relation to clinical findings of the impairment experienced by veterans with certain degrees and types of hearing disability. In support of this finding, the Board points to the regulatory history of 38 C.F.R. §§ 4.85 and 4.86. In this regard, the rating criteria for hearing loss were last revised, effective June 10, 1999. See 64 Fed. Reg. 25206 (May 11, 1999). In forming these revisions, VA sought the assistance of the Veteran's Health Administration (VHA) in developing criteria that contemplated situations in which a Veteran's hearing loss was of such a type that speech discrimination tests may not reflect the severity of communicative functioning these veterans experienced or that was otherwise an extreme handicap in the presence of any environmental noise, even with the use of hearing aids. VHA found, through clinical studies of veterans with hearing loss, that when certain patterns of impairment are present, a speech discrimination test conducted in a quiet room with amplification of the sounds does not always reflect the extent of impairment experienced in the ordinary environment. The decibel threshold requirements for application of Table VIA were based on the findings and recommendations of VHA. The intended effect of the revision was to fairly and accurately assess the hearing disabilities of veterans as reflected in a real life industrial setting. Accordingly, the Board finds that functional impairment due to hearing loss that is affected by background or environmental noise is a disability picture that is considered in the current schedular rating criteria. Therefore, the Veteran's difficulty hearing conversations, either over the phone or in person, or other noises is a factor contemplated in the regulations and rating criteria as defined. Accordingly, the Board determines that the Veteran's complaints of hearing difficulty and the functional impairment associated therewith have been considered under the numerical criteria set forth in the rating schedule. Therefore, the rating criteria reasonably describe the Veteran's disability levels and symptomatology, and referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b) (1) is not warranted. The Court, in Rice v. Shinseki, 22 Vet. App. 447 (2009), held that a claim for a total rating based on unemployability due to service- connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not argued, and the record does not otherwise reflect, that the bilateral hearing loss disability renders him unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised. ORDER Service connection for prostate cancer as due to herbicide exposure is granted. Service connection for hypertension, to include as due to herbicide exposure, is denied. An initial disability rating of 10 percent for bilateral hearing loss prior to April 7, 2011 is granted; an initial disability rating in excess of 10 percent for any period is denied. REMAND Service Connection for Degenerative Joint Disease of Neck and Back At the Board hearing, the Veteran contends that he currently has degenerative joint disease of the neck and back due to service. The service treatment records show treatment for a "crick in the neck" in June 1948 and a "stiff neck" in September 1955. The service treatment records also show complaint of moderate lumbar pain with report of prior strain three months earlier in June 1948, back ache in July 1948, back ache for one week in July 1951, and report of occasional muscle spasm in the low back on the August 1970 service retirement report of medical history. Additionally, the Veteran was in two motor vehicle accidents during service. The August 1949 motor vehicular accident caused back injury, and the June 1950 motor vehicular accident was of sufficient impact to have caused contusions of the abdominal wall after the car was forced over an embankment. A VA medical examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). In this case, the Veteran has competently reported that he currently has symptoms of, and is being treated for, a neck and back disability. See Board hearing transcript, page 12. The service treatment records show complaint and treatment for neck and back problems during service and document two in-service motor vehicular accidents that caused back injury and the impact of which may have resulted in neck injury. At the Board hearing, the Veteran testified that he continued to have back and neck problems after service. See Board hearing transcript, page 12. A VA medical examination with a medical opinion has not yet been provided to the Veteran, and the evidence currently of record is insufficient to decide the claims. For these reasons, a remand is warranted for a VA medical examination with a medical opinion is warranted. Service Connection for Colon Cancer The Veteran seeks service connection for colon cancer, to include on the basis that it had its onset during service (i.e., on a direct basis) or is secondary to the now service-connected prostate cancer. See Board hearing transcript, page 3. At the Board hearing, the representative noted that the Veteran's service treatment records show that the Veteran had a sigmoid colonoscopy in August 1970 and asked that the treatment record be considered by a physician in determining whether symptoms of the Veteran's colon cancer manifested during service. Also, the representative asked that a physician consider whether the Veteran's prostate cancer may have metastasized from the prostate to the colon. The Veteran has not yet been provided with a VA medical examination with a medical opinion in connection with the issue of service connection for colon cancer. For these reasons, a remand is warranted for a VA medical examination with a medical opinion is warranted. McLendon v. Nicholson, 20 Vet. App. at 81-82. Accordingly, the issues of service connection for degenerative joint disease of the neck and back and service connection for colon cancer are REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. Schedule the Veteran for a VA medical examination for the claimed degenerative joint disease of the neck and back. All relevant documents should be made available to and reviewed by the examiner in rendering the opinion. The examiner should confirm that the record was reviewed. Based on review of the record, the examiner should, for each diagnosed disability, provide the following opinion: a. Is it at least as likely as not (i.e., to at least a 50 percent degree of probability) that a current back/thoracolumbar spine disability had its onset during or is causally or etiologically related to the low back injury and/or low back symptomatology during service? a. Is it at least as likely as not (i.e., to at least a 50 percent degree of probability) that a current neck/cervical spine disability had its onset during or is causally or etiologically related to either of the motor vehicular accidents and/or neck symptomatology during service? In rendering the medical opinion, the examiner is asked to consider the Veteran's service treatment records reflecting treatment for a "crick in the neck" in June 1948 and a "stiff neck" in September 1955, as well as complaint of moderate lumbar pain with report of prior strain three months earlier in June 1948, back ache in July 1948, back ache for one week in July 1951, and report of occasional muscle spasm in the low back on the August 1970 service retirement report of medical history. The examiner should also consider the fact that the Veteran was in two motor vehicle accidents during service. The August 1949 motor vehicular accident caused back injury, and the June 1950 motor vehicular accident was of sufficient impact/severity to have caused contusions of the abdominal wall after the car was forced over an embankment. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of evidence both for and against a conclusion is so evenly divided that it is as sound to find in favor of causation as it is to find against it. Note: A rationale should be provided for all opinions given, and the factors upon which each medical opinion is based must be set forth in the report. If the examiner cannot answer any question posed without resorting to speculation, the examiner should so state, and explain why that is so. 2. Schedule the Veteran for a VA medical examination for the claimed colon cancer. All relevant documents should be made available to and reviewed by the examiner in rendering the opinion. The examiner should confirm that the record was reviewed. Based on review of the record, the examiner should provide the following opinion: a. Is it as likely as not (i.e., to a 50 percent degree of probability or greater) that the Veteran's colon cancer was caused by the service-connected prostate cancer? Please explain your answer. Please consider the Veteran's contention that cancer metastasized from the prostate to the colon. b. Is it as likely as not (i.e., to a 50 percent degree of probability or greater) that the Veteran's colon cancer was aggravated (i.e., permanently worsened beyond the normal progression) by the service-connected prostate cancer? Please explain your answer. If the examiner concludes that the current colon cancer was aggravated by the service-connected prostate cancer, the examiner should attempt to identify the baseline level of severity before the onset of aggravation. c. Is it at least as likely as not (i.e., to at least a 50 percent degree of probability) that the Veteran's colon cancer had its onset during or is causally or etiologically related to service, to include exposure to herbicide agents? The examiner should consider the August 1970 sigmoid colonoscopy report in the service treatment records, as well as the Veteran's presumed exposure to herbicide agents during Thailand service. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of evidence both for and against a conclusion is so evenly divided that it is as sound to find in favor of causation or aggravation as it is to find against it. Note: A rationale should be provided for all opinions given, and the factors upon which each medical opinion is based must be set forth in the report. If the examiner cannot answer any question posed without resorting to speculation, the examiner should so state, and explain why that is so. 3. After any additional notification and/or development deemed necessary is undertaken, readjudicate the remanded issues. If any benefit sought on appeal remains denied, provide a Supplemental Statement of the Case with an appropriate period of time for response by the Veteran and the representative. Thereafter, return the case to the Board for further appellate consideration, if in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs