Citation Nr: 1330959 Decision Date: 09/26/13 Archive Date: 09/30/13 DOCKET NO. 09-22 859 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for a gastrointestinal disorder, to include a gastric ulcer. 3. Entitlement to an initial disability evaluation in excess of 10 percent for generalized anxiety disorder with posttraumatic stress disorder (PTSD). 4. Entitlement to an initial disability evaluation in excess of 10 percent for right eye diplopia. 5. Entitlement to an initial compensable disability evaluation for hemorrhoids. 6. Entitlement to an initial compensable disability evaluation for right elbow ulnar tunnel syndrome. 7. Entitlement to an initial compensable disability evaluation for left elbow ulnar tunnel syndrome. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. R. Mullins, Counsel INTRODUCTION The Veteran had active service from October 1999 to December 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified at a hearing before the undersigned at the RO in Waco, Texas in May 2013. A transcript of this hearing has been prepared and associated with the Veteran's electronic paperless claims file (Virtual VA). The Veteran's claim was previously treated as one of entitlement to service connection for a gastric ulcer. However, during his May 2013 hearing, the Veteran clarified that he was in fact seeking service connection for his gastrointestinal symptomatology in general. He was not certain of the proper diagnosis. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that the scope of a mental health disability claim includes any mental health disability that could reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. In Brokowski v. Shinseki, 23 Vet. App. 79 (2009), the Court extended the holding of Clemons to include disabilities outside of psychiatric disorders. In compliance with this case law, the Board considers the Veteran's claim of service connection for a gastric ulcer to be one of any gastrointestinal disorder associated with his reported symptomatology. The issue has thus been restated on the first page. In addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the documents in said file reveals additional VA treatment records and a hearing transcript, as well as documents that are either duplicative of the physical evidence in the paper claims file. The issues of entitlement to service connection for a gastrointestinal disability, as well as entitlement to increased disability evaluations for a generalized anxiety disorder with PTSD, hemorrhoids, and ulnar tunnel syndrome of the elbows, bilaterally, 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 tinnitus manifested as a result of active military service. 2. The Veteran's right eye diplopia has been manifested by corrected distant vision of the right eye to 20/20, no impairment of the visual field, diplopia when looking to the right that did not affect the normal reading area and a Goldmann visual field test that was within normal limits. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for tinnitus have been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria for establishing entitlement to a disability evaluation in excess of 10 percent for right eye diplopia have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.321(b)(1), 3.350, 3.383, 4.1- 4.7, 4.16(b), 4.21, 4.75, 4.76, 4.78, 4.79, 4.80, 4.84(a), Diagnostic Codes 6063 to 6090 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify VA has a duty to notify and assist veterans in substantiating a claim 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 and 3.326(a) (2012). Proper notice from VA must inform the Veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide in accordance with 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). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Regarding the claim of entitlement to service connection for tinnitus, the Board is granting this claim in full. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. As for the claim of entitlement to an initial disability evaluation in excess of 10 percent for right eye diplopia, this claim arises from his disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), Goodwin v. Peake, 22 Vet. App. 128, 134 (2008), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required for this claim. Under these circumstances, the Board finds that the notification requirements have been satisfied as to both timing and content. Adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board that complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA obtained the Veteran's service treatment records. Also, the Veteran received VA medical examinations in March 2008, May 2010 and December 2011, and VA has obtained these records as well as the records of the Veteran's outpatient treatment with VA. Copies of private treatment records have also been associated with the claims file. Significantly, neither the Veteran nor his representative has identified any additional existing evidence that is necessary for a fair adjudication of the claim that has not yet been obtained. As already noted, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that a Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the undersigned noted the issues on appeal and solicited information regarding the occurrence of injuries and onset of his symptomatology as well as the functional impact the claimed disabilities have on his daily life and employment. The Veteran was also advised of types of evidence that could be identified or submitted to further substantiate the claims. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claims. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Relevant Laws and Regulations Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). To establish service connection, there must be: (1) a current disability; (2) evidence of in-service occurrence or aggravation of a disease or injury; and (3) evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999) (citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2012). A recent decision of the United States Court of Appeals for the Federal Circuit (Federal Circuit Court), however, clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). Tinnitus The Veteran contends that he is entitled to service connection for tinnitus. Having reviewed the evidence of record, and considered it in a light most favorable to the Veteran, the Board finds that service connection for tinnitus is warranted. The Veteran's service treatment records do not reflect treatment for, or complaints of, tinnitus during active military service. The records do reflect that the Veteran sustained a right orbital fracture in August 2006. In May 2007, the Veteran reported headaches since this injury with some nausea, phono/photophobia and dizziness. He did not endorse ringing in the ears or tinnitus at this time. Therefore, there is no medical evidence of this condition during active service. Nonetheless, the Board does not dispute that the Veteran was exposed to noise during his military service. The Veteran's DD-214 confirms that he worked in the Air Force. The Veteran testified in May 2013 to being exposed to a great deal of noise during his service with the Air Force. A September 2001 audiogram does specifically note that the Veteran was "Routinely Noise Exposed." An August 2005 audiogram also reflects "Steady Noise Exp." The Veteran has also testified that he experienced ringing in his ears during military service and that this ringing had continued since that time. The Veteran is competent to discuss observed physical symptoms, such as ringing in the ears. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Charles v. Principi, 16 Vet. App. 370, 374-75 (2002) ("ringing in the ears is capable of lay observation"). As such, the Board finds the Veteran's testimony on this matter to be significantly probative. Tinnitus, moreover, is a disorder uniquely ascertainable by the senses. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The record also reflects that the Veteran was treated with complaints of tinnitus in March 2008 - less than 4 months after his separation from active duty. The Veteran reported a gradual onset of ringing tinnitus beginning in 2001 to 2002. The Veteran reported that this occurred 4 to 5 times per week and lasted for 3 to 4 hours. Resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for tinnitus is warranted. Service records clearly support in service noise exposure. Furthermore, the Veteran sought treatment for this condition within a few months of separation from active duty. The Veteran has also offered competent and credible testimony of ringing in the ears during, and since, military service. As such, service connection for tinnitus is warranted and the claim is granted. Increased Rating Claims Relevant Laws and Regulations Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings will be applied, the higher rating will be assigned if the disability picture more closely approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7 (2011). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). See also 38 C.F.R. §§ 4.1, 4.2 (2011). As such, the Board has considered all of the evidence of record. However, the most probative evidence of the degree of impairment consists of records generated in proximity to and since the claim on appeal. As is the case here, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, in Fenderson v. West, the Court noted that where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" is required. 12 Vet. App. 119, 126 (1999). Right Eye Diplopia The Veteran contends that he is entitled to an initial disability evaluation in excess of 10 percent for right eye diplopia. However, as outlined below, the preponderance of the evidence of record demonstrates that the Veteran has not met the criteria for a disability evaluation in excess of 10 percent at any time during the pendency of his claim. As such, a higher disability evaluation is not warranted. The Veteran was afforded a VA examination of the eyes in March 2008. It was noted that the Veteran was suffering from diplopia in the extremes of gaze. The Veteran's corrected distant visual acuity was 20/20, bilaterally. A diplopia fields test was performed, showing a very minor degree of diplopia in the extremes of gaze. It was noted that the Veteran had no difficulty in the usual position of reading and driving a car. The Veteran was diagnosed with diplopia in the extreme fields of gaze, status post blowout fracture of the right orbit. According to a June 2009 VA outpatient treatment record, the Veteran had worsening of the visual field. An August 2009 record reflects visual acuity of 20/30 bilaterally. It is not clear whether this was corrected acuity or not, or, whether it was near vision or distant vision. The Veteran was afforded an additional VA examination of the eyes in May 2010. The Veteran reported that his diplopia had worsened in the past 2 years. Examination revealed corrected distant vision to be 20/20, bilaterally. It was noted that a diplopia fields test was abnormal and that this test would accompany the examination report. It does not appear that this was in fact associated with the record. Nonetheless, the Veteran was afforded an additional examination in December 2011. The Veteran reported having double vision when he looked to his right, but it was fine when reading or writing. The Veteran's corrected distant vision was 20/20, bilaterally. A visual field test was done and deemed to be within normal limits. A diplopia field test was also done, revealing diplopia when the Veteran looked to the right. He had no diplopia in the normal reading area and he had no difficulty performing his duties. A Goldmann visual field test was also done and deemed to be within normal limits. The preponderance of the above evidence demonstrates that the Veteran is not entitled to a disability evaluation in excess of 10 percent for right eye diplopia at any time during the pendency of this claim. In rating impairment of visual acuity, the best distant vision obtainable after best correction with glasses will be the basis of rating, except in cases of keratoconus in which contact lenses are medically required. 38 C.F.R. § 4.75. As the Veteran has routinely been found to have corrected distant vision to 20/20, a compensable evaluation is not warranted based on loss of visual acuity. See 38 C.F.R. § 4.84(a) (2008). Visual impairment can also be rated on the basis of loss of field of vision. 38 C.F.R. § 4.76. Under Diagnostic Code 6080, under which the Veteran is presently rated, a 10 percent disability evaluation is warranted when only one eye is involved for loss of the temporal half of the visual field, loss of the nasal half of the visual field, field of vision to 30 degrees but not to 15 degrees, field of vision to 45 degrees but not to 30 degrees and field of vision to 60 degrees but not to 45 degrees. 38 C.F.R. § 4.84a. A higher evaluation of 20 percent is warranted, when only one eye is involved, when the visual field is to 15 degrees but not to 5 degrees. Id. According to the December 2011 VA examination report, the Veteran's field of vision was within normal limits. While there was evidence of diplopia when the Veteran looked to the right, this did not impact his duties or his ability to read or write. There is no medical evidence to suggest that the Veteran's field of vision has been so impaired at any time during the pendency of this claim as to warrant a rating in excess of 10 percent. The Board recognizes that higher disability evaluations are available under Diagnostic Code 6090, which specifically deals with diplopia. Under this code, varying degrees of diplopia, or muscle impairment, are to be rated based on an equivalent impairment of visual acuity. See 38 C.F.R. § 4.84a. The measurement of muscle function will be performed using a Goldmann Perimeter Chart. 38 C.F.R. § 4.77. In this case, Goldmann testing was deemed to be normal in December 2011, reflecting that a higher rating would not be warranted for impairment of muscle function under Diagnostic Code 6090. The March 2008 VA examination report also notes that a diplopia fields test was performed, revealing only a very minor degree of diplopia. During the pendency of the appeal, the criteria for rating eye disabilities were amended effective December 10, 2008, but these amended criteria govern cases only when the claim is filed on or after that date. 73 Fed. Reg. 66543 (November 10, 2008). Here, because the Veteran filed his claim prior to December 10, 2008, the appeal will be considered under the prior criteria. 73 Fed. Reg. 66543 (Nov. 10, 2008). The preponderance of the above evidence demonstrates that the Veteran is not entitled to a disability evaluation in excess of 10 percent for his service-connected right eye diplopia at any time during the pendency of this claim. The Veteran has maintained corrected distant visual acuity of 20/20 in both eyes. Furthermore, visual field testing was deemed to be within normal limits, as was Goldmann visual field testing in 2011. A diplopia field test also revealed a very minor degree of diplopia only in the extremes of gaze. Therefore, the criteria for a schedular rating in excess of 10 percent for diplopia of the right eye have not been satisfied at any time during the pendency of this claim. The Board recognizes that the Veteran believes he is entitled to a disability evaluation in excess of 10 percent for his service-connected diplopia of the right eye. The Veteran testified in May 2013 that when he looked to his side or when his eye would get tired he would experience double vision. He also indicated that his doctors had suggested he try an eye patch to resolve this issue. While the Board is sympathetic to the Veteran's situation, he has not described any symptomatology that would warrant a higher schedular rating in this case. The evidence already reflects that the Veteran does experience some double vision. However, a Goldmann visual field test was performed, and interpreted to be within normal limits, demonstrating that the Veteran's diplopia is not of sufficient severity to warrant a higher rating under 38 C.F.R. § 4.84a. The Veteran is competent to report on symptoms and credible to the extent that he sincerely believes the severity of his diplopia warrants a higher rating. His competent and credible lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the diplopia based on objective data. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. The medical evidence shows that a higher evaluation is not warranted. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to an initial disability evaluation in excess of 10 percent for diplopia of the right eye must be denied. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. In this regard, to accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The provisions of 38 C.F.R. § 3.321(b) state as follows: Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service- connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. In Thun v. Peake, 22 Vet. App. 111 (2008), the Court specified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. VA's General Counsel has stated that consideration of an extra-schedular rating under 3.321(b)(1) is only warranted where there is evidence that the disability picture presented by the Veteran would, in that average case, produce impairment of earning capacity beyond that reflected in the rating schedule or where evidence shows that the Veteran's service-connected disability affects employability in ways not contemplated by the rating schedule. See VAOPGCPREC 6-96 (Aug. 16, 1996). In Thun, the Court further explained that the actual wages earned by a particular Veteran are not considered relevant in the calculation of the average impairment of earning capacity for a disability, and contemplate that Veterans receiving benefits may experience a greater or lesser impairment of earning capacity than average for their disability. The Thun Court indicated that extraschedular consideration cannot be used to undo the approximate nature of the rating system created by Congress. The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. However, the Board is not precluded from raising this question, see Floyd v. Brown, 9 Vet. App. 88 (1996), and addressing referral where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board is aware of the Veteran's complaints as to the effects of his service-connected diplopia of the right eye on his activities of work and daily living. In the Board's opinion, all aspects of this disability are adequately encompassed in the assigned schedular ratings. In this respect, the Veteran complains of blurred vision when his eyes become tired or when he looks to his "extremities." His 10 percent rating contemplates some degree of impairment of the visual field. In short, the Board finds that the assigned schedular evaluation is adequate. As such, there is no basis for extraschedular referral in this case. See Thun, 22 Vet. App. 111, 114-15 (2008). ORDER The claim of entitlement to service connection for tinnitus is granted. The claim of entitlement to an initial disability evaluation in excess of 10 percent for right eye diplopia is denied. REMAND Service Connection for a Gastrointestinal Disorder The Veteran contends that he is entitled to service connection for a gastric ulcer. Regrettably, a remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the appellant's claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. As discussed in the introduction section, the Veteran has claimed service connection for a gastric ulcer. However, it is clear from the Veteran's May 2013 testimony that he is seeking service connection for a gastrointestinal disorder in general, as he is not sure of the proper diagnosis himself. The Veteran reported that he often felt nauseated and that he would get the sensation that digested items were trying to come up his throat. He indicated that he thought he had been diagnosed with a gastric ulcer, but he also reported having been diagnosed with gastroesophageal reflux disease (GERD). As such, it is clear that the Veteran is seeking service connection for the symptomatology associated with his gastrointestinal system, rather than any one specific disability. The Veteran's service treatment records do reflect a history of gastroenteritis. This is noted in April 2006 and August 2007. The August 2007 record also notes problems with nausea with vomiting. A July 2007 record also notes complaints of gastrointestinal bleed and vomiting with blood. A diagnosis of likely peptic ulcer disease was assigned, but it was noted that further testing would be needed to exclude a colon ulcer, polyp or colitis. The record does not reflect that this diagnosis was confirmed. Following the Veteran's separation from active duty, a January 2009 private treatment record reflects that the Veteran had a previous diagnosis of gastroesophageal reflux. A prior computed tomography (CT) scan of the abdomen performed in December 2008, however, revealed the spleen, adrenals, stomach, visualized small bowel and visualized colon to be within normal limits. A subsequent VA treatment record dated June 2009 reflects a diagnosis of GERD as well, but it was noted that there were no ulcers. In light of the above evidence, the Board finds that a VA examination is warranted to determine whether the Veteran suffers from a current gastrointestinal disability, to include GERD, ulceration or any other disability that manifested during, or as a result of active military service. The examiner should consider and discuss the Veteran's in-service history of gastritis when formulating an opinion. Also, while it is unclear whether the Veteran continues to have a diagnosed gastrointestinal disability, the above diagnoses of GERD were made during the pendency of the Veteran's claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (noting that the requirement of a current disability is satisfied when the Veteran has a disability when a claim for compensation for that disability is filed, or, at any time during the pendency of the claim). As such, the Veteran should be afforded a VA examination in which an opinion is offered as to whether any gastrointestinal disability diagnosed during the pendency of the Veteran's claim manifested during, or as a result of, active military service. Generalized Anxiety Disorder with PTSD The Veteran also contends that he is entitled to an initial disability evaluation in excess of 10 percent for his service-connected generalized anxiety disorder with PTSD. The record reflects that the Veteran was most recently afforded a VA examination for his service-connected psychiatric disorder in December 2011. The Board will seek another exam. In addition, the most recent evidence of treatment from a VA medical facility is dated December 2011. Records prepared since this time should be obtained and incorporated into the Veteran's claims file, either physically or electronically. Hemorrhoids The Veteran also contends that he is entitled to an initial compensable disability evaluation for his service-connected hemorrhoids. However, additional evidentiary development is necessary before appellate review may proceed on this issue as well. The record reflects that the Veteran was last afforded a VA examination for his hemorrhoids in April 2010. According to the April 2010 VA examination report, the Veteran suffered from internal hemorrhoids that were inactive. There were no signs of external hemorrhoids at this time. However, the Veteran testified in May 2013 that he continued to suffer from external hemorrhoids, as well as blood in his stool. He also endorsed having hemorrhoids that he would describe as large and thrombotic. In light of this evidence, the Board finds that the Veteran should be scheduled for a more recent VA examination regarding his service-connected hemorrhoids. The duty to conduct a contemporaneous examination is triggered when the evidence indicates that there has been a material change in disability or that the currently assigned disability rating may be incorrect. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that a Veteran is entitled to a new examination after a 2 year period between the last VA examination and the Veteran's contention that the pertinent disability had increased in severity). In light of the length of time that has elapsed since the Veteran's last examination, and the statements provided by him suggesting a change in the severity of his disability, he should be afforded the opportunity to appear for a more recent VA examination to determine the current level of severity of his service-connected hemorrhoids. The Board notes that a December 2011 VA general examination report does indicate that there were no conditions associated with the abdomen and/or the digestive system. The questionnaire contained a lengthy list of various conditions of the digestive system, including hemorrhoids. None of the conditions listed were checked off. However, it is not clear whether a full rectal examination was performed at this time, and the Veteran subsequently endorsed symptomatology associated with his hemorrhoids in May 2013. Therefore, this record does not obviate the need for further examination. Right and Left Ulnar Tunnel Syndrome Finally, the Veteran contends that he is entitled to compensable disability evaluations for his service-connected ulnar tunnel syndrome of the right and left elbows. Regrettably, further evidentiary development is required before appellate review may proceed on these issues as well. The record reflects that the Veteran was last afforded a VA examination for these disabilities in May 2010. The examiner noted that the Veteran reported developing paresthesias in the fourth and fifth fingers on a daily basis while using a keyboard. The Veteran reported that his symptoms were worsening. Examination revealed no pain at the endpoints of motion. Muscle strength and grip strength were also deemed to be normal, bilaterally. It was also noted that the Veteran's symptoms did not occur while he was sleeping. However, the Veteran testified in May 2013 that he had a weakened grip now in each hand. He also described intermittent numbness throughout that was present at night and while at work. He also reported painful motion when trying to extend out his elbows. This testimony suggests a change in symptomatology since the Veteran's last examination of May 2010. Again, the duty to conduct a contemporaneous examination is triggered when the evidence indicates that there has been a material change in disability or that the currently assigned disability rating may be incorrect. See Caffrey v, 6 Vet. App. at 381; see also Snuffer, 10 Vet. App. at 403 (holding that a Veteran is entitled to a new examination after a 2 year period between the last VA examination and the Veteran's contention that the pertinent disability had increased in severity). Therefore, the Veteran should be provided the opportunity to appear for a more recent examination to determine the current level of severity of his ulnar tunnel syndrome of the elbows, bilaterally. Accordingly, the case is REMANDED for the following action: 1. Obtain pertinent records of VA evaluation and/or treatment of the Veteran dating since December 2011. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with respect to requesting records from Federal facilities. All records/responses received should be associated with the claims file. 2. The Veteran should also be contacted and asked to identify any other current treatment he has received for his claimed disabilities outside of VA that he wants considered. The Veteran should be asked to provide VA with proper consent forms to obtain any identified records. If the Veteran notifies VA of any additional treatment, VA should then attempt to obtain all relevant records from these facilities. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. After all records and/or response(s) from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo a gastrointestinal examination. The Veteran's claims file and a copy of this remand must be provided to the examiner for review and the examination report should reflect review of these items. The examiner is asked to opine as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that any gastrointestinal disability diagnosed during the pendency of the Veteran's appeal (including GERD in June 2009), is etiologically related to any symptomatology noted in service. In formulating the above opinion, the examiner should consider the in-service diagnoses of gastroenteritis, as well as the Veteran's lay assertions regarding chronic symptomatology. A complete rationale for all opinions offered must be provided. 4. The Veteran should also be scheduled for an examination before an appropriate examiner (other than the examiner who conducted the December 2011 VA examination) to determine the current level of severity of his service-connected generalized anxiety disorder with PTSD. The Veteran's claims file and a copy of this remand must be provided to the examiner for review, and the examination report should reflect review of these items. All indicated tests and studies should be performed, and the examiner is asked to describe in detail all symptomatology associated with the Veteran's service-connected PTSD. The Veteran's lay statements regarding the severity of his symptomatology should also be considered and discussed. The examiner should also discuss in detail the impact this condition has on the Veteran's employability. 5. The Veteran should also be scheduled for a VA examination before an appropriate examiner to determine the current severity of his service-connected hemorrhoids. The Veteran's claims file and a copy of this remand must be provided to the examiner for review, and the examination report should reflect review of these items. All indicated tests and studies should be performed, and the examiner is asked to describe in detail all symptomatology associated with the Veteran's hemorrhoids. The examiner should identify whether external and/or internal hemorrhoids are present, and if so, whether they are large or thrombotic with excessive redundant tissue evidencing frequent recurrences, or, whether they are associated with persistent bleeding with anemia and/or fissures. The Veteran's lay assertions regarding his symptomatology should also be noted in the examination report. 6. Finally, the Veteran should be scheduled for a VA examination before an appropriate examiner to determine the current severity of his service-connected ulnar tunnel syndrome of the upper extremities, bilaterally. The Veteran's claims file and a copy of this remand must be provided to the examiner for review, and the examination report should reflect review of these items. All indicated tests and studies should be performed, and the examiner is asked to describe in detail all symptomatology associated with this condition. The Veteran's lay assertions regarding his symptomatology should also be noted in the examination report. 7. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268 (1998). 8. Thereafter, readjudicate the claims on appeal in light of all pertinent medical evidence (to include any added to the record since the last adjudication of the claims) and legal authority. If any benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate supplemental statement of the case (SSOC) that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs