Citation Nr: 1334507 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 09-29 434 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. What evaluation is warranted for athlete's foot from November 16, 2006? 2. What evaluation is warranted for residuals of abdominal wall abscess from November 16, 2006? 3. What evaluation is warranted for residuals of a tongue injury from November 16, 2006? 4. Entitlement to service connection for rhinitis, also claimed as sinusitis. 5. Entitlement to service connection for gastroesophageal reflux disease. 6. Entitlement to service connection for irritable bowel syndrome with bleeding ulcers. 7. Entitlement to service connection for residuals of a deviated nasal septum due to fracture. 8. Entitlement to service connection for tinnitus. 9. Entitlement to a 10 percent evaluation based on multiple, noncompensable, service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Mary E. Rude, Associate Counsel INTRODUCTION The Veteran served on active duty from September 2005 to November 2006. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans' Appeals (Board) from a rating decision of the VA Regional Office in Boston, Massachusetts. The Virtual VA electronic claims file has been reviewed; a review of the documents in such file reveals that it contains a transcript of the March 2013 Board hearing testimony. The issues of what evaluation is warranted for residuals of a tongue injury from November 16, 2006; entitlement to service connection for rhinitis, also claimed as sinusitis, gastroesophageal reflux disease, irritable bowel syndrome with bleeding ulcers, residuals of a deviated nasal septum due to fracture, and tinnitus; and entitlement to a 10 percent evaluation based on multiple, noncompensable service-connected disabilities 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. Since November 16, 2006, the Veteran's athlete's foot has affected less than one percent of his exposed skin and total body surface area and it has not required systemic therapy such as corticosteroids or other immunosuppressive drugs. 2. Since November 16, 2006, the Veteran's residuals of an abdominal wall abscess are manifested by a scar measuring approximately 1.2 square centimeters. The scar is not unstable, tender on palpation, or causing limitation of function. CONCLUSIONS OF LAW 1. Since November 16, 2006, the Veteran's athlete foot has not met the criteria for a compensable evaluation. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Codes 7806, 7813 (2013). 2. Since November 16, 2006, the Veteran's residuals of abdominal wall abscess have not met the criteria for a compensable evaluation. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.20, 4.118 (2013); 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in December 2006 and February 2007 of the information and evidence needed to substantiate and complete the claims, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. The case was most recently readjudicated in June 2009. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate the claims, and as warranted by law, affording VA examinations. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. Relevant Laws and Regulations Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings 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 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). In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The United States Court of Appeals for Veterans Claims also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126-27. Where there is a question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Under Diagnostic Code 7813, dermatophytosis (ringworm: of body, tinea corporis; of head, tinea capitis; of feet, tinea pedis; of beard area, tinea barbae; of nails, tinea unguium; of inguinal area (jock itch), tinea cruris) should be rated as disfigurement of the head, face or neck, scars, or dermatitis, depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7813. Under Diagnostic Code 7806, dermatitis or eczema covering less than 5 percent of the entire body, affecting less than 5 percent of exposed areas, and requiring no more than topical therapy during the past 12-month period warrants a noncompensable rating. Dermatitis or eczema covering at least 5 percent (but less than 20 percent) of the entire body, affecting at least 5 percent (but less than 20 percent) of exposed areas, or requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period warrants a 10 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7806. To meet the criteria for a 10 percent rating, the Veteran is not required to meet each of the stated criteria in order to warrant an increased rating. Rather, he need only meet one criterion because the criteria are listed in the alternative. See Johnson v. Brown, 7 Vet. App. 95 (1994). Regarding residuals of abdominal wall abscess, the Veteran filed his claim in November 2006. In August 2007, the RO granted service connection and assigned a noncompensable rating pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7805, the rating criteria for scars and the most analogous to the predominant characteristic of the Veteran's disability. During the course of the Veteran's appeal, VA revised the rating criteria for evaluating scars, effective October 23, 2008. See 73 Fed. Reg. 54710 (October 23, 2008). Pursuant to the revised regulation, 38 C.F.R. § 4.118, a veteran who has been rated by VA under Diagnostic Codes 7800, 7801, 7802, 7803, 7804, or 7805 prior to October 23, 2008 may request review under the new version of Diagnostic Codes 7800, 7801, 7802, 7804, and 7805 irrespective of whether the disability has increased since the last review. Here the Veteran has requested no such review, and the appropriate criteria for application for the entirety of the period on appeal is that of the regulation in effect prior to October 23, 2008, and is set forth below. Prior to October 23, 2008, scars of other than the head, face, or neck that are deep or that cause limited motion were rated 10 percent disabling if involving an area or areas exceeding 6 square inches (39 square centimeters). 38 C.F.R. § 4.118, Diagnostic Code 7801 (2008). Note (2) to Diagnostic Code 7801 provides that a deep scar is one associated with underlying soft tissue damage. Id. Superficial scars of other than the head, face, or neck, which did not cause limited motion and which covered an area or areas of 144 square inches (929 square centimeters) or greater were assigned a 10 percent disability rating. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2008). A superficial scar was defined as one not associated with underlying soft tissue damage. Id. at Note (2). Superficial unstable scars were assigned a 10 percent disability rating. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2008). An unstable scar was defined as one where, for any reason, there is frequent loss of covering of skin over the scar. Id. at Note (1). Superficial scars which were painful on examination were assigned a 10 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). Other scars were to be rated on the limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Athlete's Foot The Veteran contends that his service-connected athlete's foot warrants a compensable initial evaluation. The RO assigned an initial noncompensable rating for athlete's foot (tinea pedis), effective November 16, 2006, pursuant to 38 C.F.R. § 4.118, Diagnostic Codes 7806, 7813. At his March 2013 Board hearing, the Veteran stated that he has athlete's foot on the inside ankles of his feet and between his toes. He described it as a "really itchy rash" that was greatly irritating, especially when wearing boots. He stated that he uses cortisone cream daily to relieve the itch and pain. The Veteran indicated that he had not received any medical treatment for athlete's foot, but only treated it himself with topical cream. The Veteran was afforded a VA examination in May 2007. He reported having symptoms of itching intermittently, as often as once a month. He reported that flare-ups interfere with sleep and that he treated it with topical medication. The examiner noted that the skin disease did not involve any areas exposed to the sun and that it caused no functional impairment. On examination, the examiner noted crusting on the interpedal areas of the foot. There was no evidence of ulceration, exfoliation, tissue loss, abnormal texture, or limitation of motion. The affected area was zero percent of exposed skin area and less than one percent of the total body area. The examiner diagnosed the Veteran with athlete's foot. Both the findings of the VA examination and the lay statements of the Veteran show that he has intermittently recurring athlete's foot on his toes and ankles, which causes itching and discomfort. The Veteran has treated this condition with topical cream, and does not receive any further medical treatment for the condition. The evidence shows that the weight of the evidence is against the assignment of a compensable disability rating for the Veteran's athlete's foot at any time since November 16, 2006. As noted above, a 10 percent rating under Diagnostic Code 7806 requires dermatitis or eczema covering at least 5 percent of the body (but less than 20 percent), affecting at least 5 percent of exposed areas (but less than 20 percent), or requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for less than six weeks during the past 12-month period. The medical evidence of record does not reflect that the Veteran has used corticosteroids or other immunosuppressive drugs for his athlete's foot at any time during the appeals period. While the VA examination report indicated that the Veteran has regularly used topical treatment, such as hydrocortisone cream, such treatment is not systemic therapy. There is otherwise no evidence to indicate the use of such drugs or therapy for treating athlete's foot in order to support a higher rating. Likewise, the pertinent medical evidence preponderates against finding that at least 5 percent of the Veteran's body or exposed areas have been affected by his skin disability. The VA examiner stated that it did not affect any of the Veteran's exposed surface area and affected less than one percent of his total body surface area. This is consistent with the Veteran's own description of his athlete's foot, as he has stated that it affects only the inside of his ankles and between his toes. At no time has any medical professional or the Veteran himself asserted that athlete's foot has affected at least 5 percent of his body or exposed areas. This finding is consistent with no more than the noncompensable rating assigned. The Board considered the Veteran's assertions concerning the discomfort and itching he has experienced from his athlete's foot, which he is competent to provide. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the minimum criteria needed to support a compensable rating-a skin disorder affecting at least 5 percent of the body, affecting 5 percent of exposed areas, or requiring intermittent systemic therapy-require medical findings which are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Hence, while the Veteran's complaints have been considered, they are not probative on these points when weighed against objective medical findings which, when applied to the criteria assigned by the regulations indicated above, do not support the claim for a compensable rating. The Board has also determined that there is no other potentially applicable diagnostic code pursuant to which any higher rating for the disability under consideration could be assigned. A 10 percent rating under Diagnostic Code 7816 (for psoriasis) or Diagnostic Code 7821 (for cutaneous manifestations of collagen-vascular diseases) also requires that the skin disability affect 5 to 20 percent of the body or exposed areas or the use of systemic therapy, such as corticosteroids or other immunosuppressive drugs. A 10 percent rating under Diagnostic Code 7817 (for exfoliative dermatitis) requires systemic therapy such as corticosteroids, immunosuppressive retinoids, psoralen with long-wave ultraviolet-A light or ultraviolet-B light treatments, or electron beam therapy. As noted above, the medical evidence of record does not support the required findings for a compensable rating. Hence, rating the disability, by analogy, under any of the aforementioned diagnostic codes would not provide a basis for assignment of a higher rating. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). The Veteran has not asserted that his athlete's foot has had any impact on employment or functioning, nor has he ever required hospitalization for this condition. Here, the rating criteria quite specifically describe the Veteran's disability level and symptomatology; thus, his disability picture is what is contemplated by the rating schedule, and the assigned schedular evaluation is adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. The evidence provides no basis to assign a staged rating for the disability, pursuant to Fenderson, and the claim of entitlement to an initial compensable rating for athlete's foot must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against assignment of any higher rating, that doctrine is not for application. See 38 U.S.C.A. § 5107(b). Abdominal Wall Abscess The Veteran also claims entitlement to a compensable rating for his service connected residuals of an abdominal wall abscess. With his August 2009 substantive appeal, he submitted a statement describing his treatment in service for a painful and necrotic spider bite abscess which had to be excised and resulted in a small abdominal scar. The Veteran's service treatment records confirm that a spider bite leading to a 1 to 1.5 centimeter methicillin-resistant staphylococcus aureus (MRSA) abscess was treated in October 2006. Another October 2006 treatment record described the abscess as measuring one centimeter with cellulites extending out two centimeters. At his March 2013 hearing, the Veteran stated that his abdominal scar was approximately six inches long, was tender to the touch, and sometimes turned red, swelled, or was painful when he sat down for long periods of time. He reported that he had not had any medical treatment or examinations for the condition. At his May 2007 VA examination, the Veteran reported having had treatment within the past year for an MRSA abscess and that he had area itchiness. Upon examination, the examiner found a level scar to the left of the umbilicus that measured 1.2 centimeters by 1 centimeter. There was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, inflammation, edema, keloid formation, hypopigmentation, hyperpigmentation, or abnormal texture. He diagnosed the Veteran with rash insect bite with infection and scar. In light of the foregoing evidence, the Board finds that entitlement to a compensable disability rating is not warranted for residuals of abdominal wall abscess at any time since November 16, 2006. As noted above, at no point has the Veteran requested that his claim be considered under the revised criteria for evaluating scars, and his claim is therefore rated solely under the prior regulations that were in effect at the time he filed his claim. See 38 C.F.R. § 4.118. There is currently only one probative, competent medical opinion of record: that of the May 2007 VA examiner. After reviewing the Veteran's history and performing a physical examination, the examiner found that the Veteran's scar measured 1.2 centimeters by 1 centimeter, and therefore certainly did not meet the criteria of measuring 144 square inches (929 square centimeters) in order to warrant a compensable rating under 38 C.F.R. § 4.118, Diagnostic Code 7802 (2008). While the examiner did not specifically note whether the Veteran's scar was deep or superficial, even considered to be a deep scar, it would not meet the criteria for a compensable rating as it did not exceed 6 square inches (39 square centimeters) in size. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2008). The examiner also found no tenderness or instability, and therefore a compensable rating cannot be assigned under 38 C.F.R. § 4.118, Diagnostic Codes 7804, 7805 (2008). In reaching the above conclusions, the Board has not overlooked the Veteran's lay statements. In this regard, the Veteran is competent to report on what he sees and feels, such as the size of a scar and pain. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). While the Veteran stated in March 2013 that his scar measured 6 inches long, the Board finds this contention not credible. When weighing the probative value of evidence, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995). In this case, the Veteran's assertion that his scar is 6 inches long is a direct contradiction to both the October 2006 service treatment record which indicated an abscess that was 1 to 1.5 centimeters long and the May 2007 examiner's finding of a scar that measured 1 centimeter by 1.2 centimeters. While the Veteran also stated that the scar was sometimes painful, the May 2007 examiner found no tenderness on examination or other abnormality. The May 2007 examination report is therefore the only highly probative evidence of the Veteran's current disability level. See Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches"). The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1); Bagwell, 9 Vet. App. at 338-39. The Veteran has not asserted that his scar has had any impact on employment or functioning, nor has he ever required hospitalization or medical treatment for the scar since his initial treatment in service. The rating criteria therefore adequately describe the Veteran's disability level and symptomatology, his disability picture is what is contemplated by the rating schedule, and referral for extraschedular consideration is not warranted. See Thun, 22 Vet. App. at 115. In sum, there is no basis for any staged rating of the disability, pursuant to Fenderson, and the claim for an initial compensable rating for residuals of abdominal wall abscess must be denied. The Board has again considered the applicability of the benefit-of-the-doubt doctrine, but as the preponderance of the evidence is against assignment of any higher rating, this rule does not apply. See 38 U.S.C.A. § 5107(b). ORDER Entitlement to a compensable evaluation for athlete's foot from November 16, 2006 is denied. Entitlement to a compensable evaluation for residuals of abdominal wall abscess from November 16, 2006 is denied. REMAND In August 2010 the Veteran was granted service connection for residuals of a tongue injury, effective date November 16, 2006. The Veteran's service treatment records show that in October 2006 he presented at sick call with a swollen and discolored tongue. He was diagnosed with a healing bite wound and questionable infection. In November 2006, he reported that he again bit his tongue and was experiencing tongue pain. At his March 2013 Board hearing, the Veteran stated that he bit his tongue in service and believed that he had "lost a lot of taste buds" and now had trouble chewing. He also stated that he now has a speech impediment due to his tongue injury. The Veteran has yet to be afforded a VA examination to assess the severity of his tongue injury residuals, and he has not submitted any medical evidence regarding its treatment or severity. The Veteran's assertions at his March 2013 Board hearing, however, indicate that he may have injury residuals more severe than the injury documented in his October and November 2006 service treatment records. Therefore, to ensure that the evidence of record reflects the current severity of the Veteran's tongue injury residuals, a contemporaneous examination is warranted. See, e.g., Caffrey v. Brown, 6 Vet. App. 377, 381 (1994). Accordingly, the RO/AMC should arrange for the Veteran to undergo an appropriate VA examination. Regarding the claim of entitlement to service connection for tinnitus, the Veteran has alleged that in service he experienced a blow to the head while playing football as well acoustic trauma from engine noise while performing ship maintenance, and these injuries led to tinnitus, which began in service and has intermittently continued since that time. The Veteran stated at his March 2013 Board hearing that he has never been clinically diagnosed with tinnitus. VA will provide a medical examination or obtain a medical opinion if the record, including lay or medical evidence, contains competent evidence of a disability that may be associated with an event, injury, or disease that occurred in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159 (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon, 20 Vet. App. at 83. In this case, the Veteran has alleged an injury in service and a continuity of symptomatology of ringing in the ears starting in service and continuing to the present. Under these circumstances, an examination of the Veteran to obtain a medical opinion by an audiologist or other appropriate medical professional, based on full consideration of the Veteran's documented medical history and assertions and supported by clearly stated rationale, is needed to resolve the claim. Id. The Veteran's claims of entitlement to service connection for rhinitis, also claimed as sinusitis, gastroesophageal reflux disease , irritable bowel syndrome with bleeding ulcers, and residuals of a deviated nasal septum due to fracture were denied by the RO on the basis that these disorders preexisted the Veteran's service. When determining service connection, a presumption of soundness applies. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b) (2013). Pursuant to such presumption, a Veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Id. To rebut the presumption of soundness, VA must show, by clear and unmistakable evidence, (1) that the disease or injury existed prior to service, and (2) that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. Id.; see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Rather, the burden of proof falls on the Secretary to demonstrate that the established pre-existing condition of a Veteran was not aggravated during service. See Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). The mere occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability; rather, the aggravation must cause a lasting worsening of the condition. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). Although the Veteran was afforded a VA examination in May 2007, the examiner was not asked to provide a medical opinion addressing the etiology of the Veteran's current diagnoses or whether the disabilities had preexisted service and been aggravated beyond their natural progression. Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, new VA examinations for rhinitis/sinusitis, gastroesophageal reflux disease, irritable bowel syndrome with bleeding ulcers, and residuals of a deviated nasal septum due to fracture, based on full consideration of the Veteran's documented medical history and assertions, and providing fully supported and stated opinions and rationale on the question of aggravation of preexisting disorders during service, are needed to resolve the claims. McLendon, 20 Vet. App. at 83. Finally, the claim of entitlement to a 10 percent rating due to multiple noncompensable disabilities under 38 C.F.R. § 3.324 (2012) is inextricably intertwined with the claims that are being remanded, and therefore should be considered together with those claims. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the current severity of his residuals of a tongue injury. All indicated tests must be accomplished. The claims folder, to include access to Virtual VA, and a copy of this remand, must be provided to and reviewed by the examiner as part of the examination. The examiner must specify in the report that the claims file and Virtual VA records have been reviewed. Following the examination, the examiner must identify all nerves affected by the Veteran's tongue injury and the extent of any impairment associated therewith, including any speech or other functional impairment. If the examiner cannot offer an opinion without resorting to speculation, he or she must so state, and explain why speculation is required to reach the opinion offered. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any current tinnitus. All indicated tests must be accomplished. The claims folder, to include access to Virtual VA, and a copy of this remand, must be provided to and reviewed by the examiner as part of the examination. The examiner must specify in the report that the claims file and Virtual VA records have been reviewed. Following the examination, the examiner must opine whether it is at least as likely as not, i.e., there is at least a 50/50 chance, that the Veteran currently has a diagnosis of tinnitus and whether tinnitus had its onset during or is otherwise related to the Veteran's service. The examiner is to provide a full rationale for his or her opinion, including addressing the Veteran's lay statements. If the examiner cannot offer an opinion without resorting to speculation, he or she must so state, and explain why speculation is required to reach the opinion offered. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his rhinitis/sinusitis. All indicated tests must be accomplished. The claims folder, to include access to Virtual VA, and a copy of this remand, must be provided to and reviewed by the examiner as part of the examination. The examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner is requested to opine whether clear and unmistakable evidence shows that rhinitis or sinusitis preexisted the Veteran's period of military service. If the examiner determines that rhinitis or sinusitis did not preexist service, he or she is requested to opine on whether any current rhinitis or sinusitis is at least as likely as not, i.e., at least a 50/50 chance, related to active military service or events therein. If the examiner determines that rhinitis or sinusitis did preexist service, he or she is requested to opine whether there is clear and unmistakable evidence that any such nasal or sinus disorder was not aggravated during the Veteran's period of active service. The term "aggravation" means an increase in disability during active service beyond the natural progress of the preexisting condition. The examiner is requested to provide a complete rationale for any opinion offered. If the examiner cannot offer an opinion without resorting to speculation, he or she must so state, and explain why speculation is required to reach the opinion offered. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of gastroesophageal reflux disease and irritable bowel syndrome with bleeding ulcers. All indicated tests must be accomplished. The claims folder, to include access to Virtual VA, and a copy of this remand, must be provided to and reviewed by the examiner as part of the examination. The examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner is requested to opine whether clear and unmistakable evidence shows that either gastroesophageal reflux disease and/or irritable bowel syndrome preexisted the Veteran's period of military service. If the examiner determines that gastroesophageal reflux disease and/or irritable bowel syndrome did not preexist service, he or she is requested to opine on whether any current disability is at least as likely as not, i.e., at least a 50/50 chance, related to active military service or events therein. If the examiner determines that gastroesophageal reflux disease and/or irritable bowel syndrome did preexist service, he or she is requested to opine whether there is clear and unmistakable evidence that any such disorder was not aggravated during the Veteran's period of active service. The term "aggravation" means an increase in disability during active service beyond the natural progress of the preexisting condition. The examiner is requested to provide a complete rationale for any opinion offered. If the examiner cannot offer an opinion without resorting to speculation, he or she must so state, and explain why speculation is required to reach the opinion offered. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of residuals of a deviated nasal septum due to fracture. All indicated tests must be accomplished. The claims folder, to include access to Virtual VA, and a copy of this remand, must be provided to and reviewed by the examiner as part of the examination. The examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The Veteran has clearly indicated that his deviated nasal septum was fractured prior to service, but asserts that it was reinjured and worsened due to the facial injury in service. The examiner is requested to opine on whether there is clear and unmistakable evidence that the Veteran's residuals of a deviated nasal septum was not aggravated during the Veteran's period of active service. The term "aggravation" means an increase in disability during active service beyond the natural progress of the preexisting condition. The examiner is requested to provide a complete rationale for any opinion offered. If the examiner cannot offer an opinion without resorting to speculation, he or she must so state, and explain why speculation is required to reach the opinion offered. 6. The RO/AMC must notify the Veteran that it is his responsibility to report for any scheduled examinations and to cooperate in the development of the claims. The consequences for failure to report for VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2012). 7. The RO/AMC must review any examination report and medical opinion to ensure that it is in complete compliance with the directives of this remand. If any report is deficient in any manner, the RO/AMC must implement corrective procedures. 8. Thereafter, the RO/AMC must readjudicate the claims. If any benefit sought is not granted, the appellant and his representative must be furnished with a supplemental statement of the case and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The appellant 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). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs