Citation Nr: 1335937 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 08-12 225 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for colon polyps, including as secondary to toxic gas exposure. 2. Entitlement to service connection for pulmonary edema. 3. Entitlement to service connection for a neck disorder. 4. Entitlement to service connection for a right knee disorder. 5. Entitlement to service connection for a right shoulder disorder. 6. Entitlement to service connection for a left knee disorder, including as secondary to a right knee disorder. 7. Entitlement to service connection for a sinus disorder. 8. Entitlement to service connection for a psychiatric disability to include posttraumatic stress disorder (PTSD). 9. Entitlement to service connection for sexual dysfunction, including as secondary to PTSD. 10. Entitlement to service connection for tinnitus. 11. Entitlement to service connection for a skin disorder, including as secondary to toxic gas exposure. 12. Entitlement to service connection for dizziness/vertigo. 13. Entitlement to service connection for a gastrointestinal disability. 14. Entitlement to a higher initial rating for a left shoulder strain, currently rated as 10 percent disabling. 15. Entitlement to a higher initial rating for restrictive airway disease, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: John S. Berry, Esq. ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran had active service from July 1993 to February 1998. These claims come before the Board of Veterans' Appeals (Board) on appeal of May 2007, July 2008, February 2103, and March 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Offices (ROs) in St. Petersburg, Florida and Roanoke, Virginia. Claims of entitlement to service connection for pulmonary edema; a neck disorder; a right knee disorder; a right shoulder disorder; a left knee disorder, including as secondary to a right knee disorder; a sinus disorder; sexual dysfunction, including as secondary to PTSD; tinnitus; a skin disorder, including as secondary to toxic gas exposure; dizziness/vertigo; and a psychiatric disability to include PTSD, were remanded in March 2010 for further development. In March 2010, the Board also issued a decision denying the Veteran's claim for service connection for colon polyps, including as secondary to toxic gas exposure. In September 2011, the United States Court of Appeals for Veterans Claims (Court) vacated the Board's decision. In March 2010, the Board also remanded the issues of entitlement to service connection for a left shoulder disability and for asthma, including as secondary to toxic gas exposure. By way of a February 2013 rating decision, the RO granted service connection for a left shoulder disability and for restrictive airway disease. In May 2013, the Veteran filed a notice of disagreement with the ratings assigned. A statement of the case was issued in July 2013; and a substantive appeal was received in July 2013. Finally, the issue of entitlement to service connection for a gastrointestinal disability was denied by way of a March 2013 rating decision. A notice of disagreement was received in May 2013; a statement of the case was issued in July 2013; and a substantive appeal was received in July 2013. The issues of entitlement to service connection for colon polyps, a neck disorder, a sinus disorder, a psychiatric disability, sexual dysfunction, tinnitus, a skin disorder, dizziness/vertigo, and gastrointestinal disability, as well as entitlement to an increased rating for a left shoulder strain, 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. Pulmonary disease (to include pulmonary edema) was not manifested during the Veteran's active duty service or for years after service, nor is it otherwise related to service. 2. A right knee disability was not manifested during the Veteran's active duty service or for years after service, nor is it otherwise related to service. 3. A left knee disability was not manifested during the Veteran's active duty service or for years after service, nor is it otherwise related to service, or due to a service connected disability. 4. A chronic right shoulder disability was not manifested during the Veteran's active duty service or for years after service, nor is it otherwise related to service. 5. The Veteran's restrictive airway disease requires daily inhalational or oral bronchodilator therapy, or inhalational anti-inflammatory medication. The disability is not manifested by forced expiratory volume in one second (FEV-1) of 40 to 55 percent predicted, or FEV-1FVC of 40 to 55 percent, or at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. CONCLUSIONS OF LAW 1. Pulmonary disease (to include pulmonary edema) was not incurred in or aggravated by the Veteran's active duty service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. A right knee disability was not incurred in or aggravated by the Veteran's active duty service, nor may it be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. A left knee disability was not incurred in or aggravated by the Veteran's active duty service, nor may it be presumed to have been incurred in or aggravated by such service, nor is it secondary to a service connected disability 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 4. A right shoulder disability was not incurred in or aggravated by the Veteran's active duty service, nor may it be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 5. The criteria for entitlement to a disability evaluation of 30 percent, for restrictive airway disease have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, Diagnostic Code 6602 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Proper notice from VA must inform the claimant 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 claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the 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. VCAA 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). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's increased rating claim for restrictive airway disease arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Here, the Veteran was sent letters in March 2007 and September 2007 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letters also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. 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). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any relevant outstanding evidence. The Veteran's representative has contended in general that the VA examinations were inadequate. However, he has reported any specific deficiency. The Board finds that the examinations were adequate in that they contain all findings needed to decide the claims, include sufficient findings, opinions and supporting rationales. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d) (2013). Service Connection Service connection will be established for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110, 1131 (West 2002). In order to establish service connection for the claimed disorder, there must be evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Where a chronic disease listed in 38 U.S.C.A. § 1101, is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2013). When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Establishing continuity of symptomatology under § 3.303(b) is an alternative method of satisfying the second and third Shedden requirements to establish chronicity of disease or injury in service and, in turn, link current disability to service. Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr, 21 Vet. App. at 307. These provisions only apply to listed chronic diseases. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A chronic disease identified to a compensable degree within one year of service is presumed to be service connected. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Pulmonary edema The Veteran contends that he developed pulmonary edema due to exposure to hydrogen sulfide; and that he continues to need inhaler therapy. The service treatment records reflect that the Veteran was treated for an upper respiratory infection (August 1996), pneumonitis (August 1996 - December 1996), and restrictive airway disease (January 1997). The January 1997 treatment report reflects that the Veteran had gradual improvement of all symptoms. The Veteran's undated separation examination yielded normal findings with regards to his lungs and chest. A February 1998 Report of Medical History reflects that the Veteran denied, by checked box, any asthma, shortness of breath, chronic cough, and pain or pressure in his chest. Chest x-rays dated from August 1996 to March 1998 reflect no heart or lung disease. The March 1998 x-ray report stated that the heart and pulmonary vessels were normal and the lung fields were clear. The Veteran underwent a VA examination in February 2013. The examiner reviewed the claims file in conjunction with the examination. The examiner noted that the Veteran was diagnosed as having pneumonitis and that it had resolved in 1997. The examiner also noted a current diagnosis of restrictive airway disease. The examiner stated that the Veteran did not have multiple respiratory conditions. The Veteran is service connected for restrictive airway disease, and the February 2013 VA examiner has determined that the Veteran does not have other respiratory conditions. Consequently, the examiner did not diagnose pulmonary edema or other additional respiratory disease. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1131; see also Degmetich v. Brown, 104 F.3d 1328 (1997). It is well-settled that in order to be considered for service connection, a claimant must first have a disability. In Brammer v. Derwinski, 3 Vet. App. 223 (1992), it was noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents resulted in disability. See also Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). The Veteran is competent to report symptoms of respiratory disability. See Charles v. Principi, 16 Vet. App. 370, 374 (2002); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Moreover, his reports are credible. However, as a lay person the Veteran is not competent to opine that his symptoms are manifestations of pulmonary edema. Such an opinion would require medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer.") "Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, [describe that issue] falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." In this case, the competent medical evidence reflects that the Veteran suffers from restrictive airway disease (for which he is already service connected) and no other respiratory disabilities. In the absence of any competent evidence showing current pulmonary edema or additional disability beyond that already service connected, the preponderance of the evidence is against the claim and reasonable doubt does not arise. Knees The service treatment records reflect that the Veteran sought treatment for a twisting injury to his right knee in August 1997. It was diagnosed as a right patellar tendon sprain. A September 1997 treatment report indicated an assessment of a medial collateral ligament sprain. An October 1997 treatment report also diagnosed it as a medial collateral ligament strain. There are no further in-service reports of further treatment. The Veteran underwent a February 1998 separation examination that yielded normal findings. He completed a February 1998 Report of Medical History in which he indicated, by check box, that he had not had any swollen or painful joints, broken bones, arthritis, rheumatism, bursitis, bone, joint or other deformity, "trick" or locked knee. He handwrote "I am in excellent health." He completed a Report of Medical History in January 1999 in which he once again denied, by check box, all of the aforementioned symptoms. The service treatment reports contained no findings attributed to a left knee disability. There are no post service records reflecting treatment of either knee. The Veteran underwent a VA examination in November 2012. The examiner reviewed the claims file in conjunction with the examination. He noted that the Veteran had a knee strain in "1996" that had resolved. The Veteran reported that he was constantly in pain. He reported that during service, he had to walk on hard, steel floors of his ship and had to climb narrow stairs. He also reported having a meniscus injury to one of the knees. He stated that he was not able to run or to walk briskly due to the pain. He also reported flare-ups that occurred with walking or standing for greater than 30 minutes, and prolonged driving. Upon examination, the Veteran achieved full range of motion in both knees without any objective evidence of pain. The Veteran had 10 degrees of limited motion after repetitive testing. He complained of pain on palpation to both knees. He had full strength in both knees, no instability in either knee, and no history of subluxation or dislocation. He did not use any assistive devices for locomotion. X-rays of both knees were normal, with no evidence of degenerative or traumatic arthritis. The examiner found that there was no functional impact of the Veteran's disability. The examiner found that the claimed disabilities were less likely than not caused by the Veteran's in-service injury. He reasoned that the Veteran had a knee strain in service; but he did not have arthritis either during service or at any time after service. There were no objective findings upon which to base a diagnosis. Analysis In this case, the Veteran has not established the first element of service connection. Although the Veteran has complained of constant pain in his knees, an underlying disability has not been identified. He has not sought treatment for a knee disability, and the November 2012 VA examiner found no objective evidence of a knee disability. The Veteran had full range of motion, full strength, no instability, and X-rays showed no degenerative changes (arthritis) or loss of range of motion. The Board notes that symptoms alone (such as pain), without a finding of an underlying disorder, cannot be service-connected. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Even if a current disability could be found, the claim falls short with regards to the third element of service connection. The lone medical opinion weighs against the claim. For chronic diseases like arthritis, service connection may be established by continuity of symptomatology under 38 C.F.R. § 3.303(b) or based on initial diagnosis after service under 38 C.F.R. § 3.303(d). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, in this case, arthritis or other chronic disease has not been identified. His right knee sprain/strain resolved. It was not noted upon the Veteran's separation examination; and the Veteran denied any knee issues in his February 1998 and January 1999 Reports of Medical History. In his claim, he stated that he has treated since 1997. However, when asked where he received treatment, he only listed the U.S.S. Wasp. Consequently, it appears that he only received treatment in service. Finally, with regards to the Veteran's left knee, the Board notes that there are no findings attributed to a left knee disability in the service treatment records. The claim is that the alleged disability is secondary to his right knee disability. The December 2012 VA examiner did not find any objective evidence of a left knee disability. Moreover, even if there was current left knee disability, it could not be service connected to his alleged right knee disability because he is not service connected for a right knee disability. In the absence of a current right knee disability and a nexus linking it to service, the preponderance of the evidence weighs against the claim. As the preponderance of the evidence is against these claims, the benefit-of-the-doubt doctrine does not apply, and the claims for service connection for right and left knee disabilities must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Right Shoulder The service treatment records reflect that the Veteran sought treatment for a painful right shoulder in May 1994. He was diagnosed as having a possible right shoulder strain. There are no further in-service reports of treatment. The Veteran underwent a February 1998 separation examination that yielded normal findings. He completed a February 1998 Report of Medical History in which he indicated, by check box, that he had not had any swollen or painful joints, broken bones, arthritis, rheumatism, bursitis, bone, or joint or other deformity. He handwrote "I am in excellent health." He completed a Report of Medical History in January 1999 in which he once again denied, by check box, all of the aforementioned symptoms. The Veteran has not indicated that he ever sought treatment (either in service or after). There are no post service treatment records of treatment for a right shoulder disability. The Veteran underwent a VA examination in November 2012. The examiner reviewed the claims file in conjunction with the examination. He noted that the Veteran had bilateral shoulder strains, and that the right shoulder strain had resolved, whereas the left shoulder strain was current. The Veteran reported that he dislocated his shoulder in 1994; but he could not remember which shoulder. It was reset and he wore a sling for a few weeks. He recalled having pain in both shoulders and that both shoulders caused pain with heavy lifting. He reported that push and pull activities cause pain in both shoulders. He reported that he experienced flare-ups of pain in that sometimes it hurt when lifting his arm. Upon examination, the examiner found that the Veteran achieved full range of motion in the right shoulder. After repetitive testing, he had less movement than normal in the left shoulder, but not in the right. There was pain to palpation in both shoulders; but guarding only of the left. He had full muscle strength. X-rays were normal. The examiner diagnosed the Veteran with a left shoulder strain; but found no pathology in the right shoulder. Analysis In this case, the Veteran has not established the first element of service connection. Although the Veteran has complained of pain in his right shoulder, he has not been found to have an underlying current disability. He has not sought any post-service treatment for a right shoulder disability, and the November 2012 VA examiner found no right shoulder disability. The Veteran had full range of motion, full strength, and X-rays revealed normal findings. The Board notes that symptoms alone (such as pain), without a finding of an underlying disorder, cannot be service-connected. See Sanchez-Benitez v. Principi. Although the service treatment records clearly reflect treatment for right shoulder pain and a diagnosis of a possible right shoulder strain. The Veteran has not been found to have a current disability. In the absence of a current right shoulder disability, the preponderance of the evidence weighs against the claim. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for a right shoulder disability must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Initial Ratings Disability evaluations 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 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. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected restrictive airway disease has been rated under the provisions of Diagnostic Code 6602 governing asthma. Under this regulatory provision, bronchial asthma with FEV-1 of 71 to 80 percent predicted, or FEV-1/FVC of 71 to 80 percent predicted, or intermittent inhalational or oral bronchodilator therapy warrants a 10 percent rating. Bronchial asthma with FEV-1 of 56 to 70 percent predicted, or FEV-1/FVC of 56 to 70 percent predicted, or daily inhalational or oral bronchodilator therapy, or inhalational anti-inflammatory medication warrants a 30 percent rating. Bronchial asthma with FEV-1 of 40 to 55 percent predicted, or FEV-1FVC of 40 to 55 percent, or at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids warrants a 60 percent rating. Bronchial asthma with FEV-1 that is less than 40 percent predicted, or FEV-1/FVC less than 40 percent, or more than one attack per week with episodes of respiratory failure, or requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications warrants a maximum 100 percent rating. 38 C.F.R. § 4.97. A July 2001 Spirometry Graphics Report reflects FVC of 97.61 percent predicted; FEV-1 of 98.08 percent predicted; and FEV-1/FVC of 96.49 percent. The results were interpreted as normal expiratory flows and a normal FVC. An August 2005 Spirometry Graphics Report reflects FVC of 99.73 percent predicted; FEV-1 of 98.80 percent predicted; and FEV-1/FVC of 96.35 percent. An August 2007 Spirometry Graphics Report reflects FVC of 94 percent predicted; FEV-1 of 98 percent predicted; and FEV-1/FVC of 104 percent. The Veteran underwent a VA examination in February 2013. The examiner reviewed the claims file in conjunction with the examination. He noted that the Veteran had been diagnosed as having chemical pneumonitis that resolved in 1997; and that the Veteran was diagnosed as having restrictive airway disease in 2013. The Veteran reported that he currently used Albuterol as needed. He reported that he got shortness of breath with strenuous activities; and that he experienced wheezing especially in cold weather or with exercise. The examiner found that the Veteran's disability did not require the use of oral or parenteral corticosteroid medications; but it did require intermittent inhaled medications. The examiner noted that December 2012 chest X-rays revealed minimal lower lobe subsegmental atelectasis. Pulmonary function tests (PFTs) revealed FVC of 88 percent predicted; FEV-1 of 90 percent predicted; and FEV-1/FVC of 82 percent. Post-bronchodilator, the PTFs revealed FVC of 86 percent predicted; FEV-1 of 90 percent predicted; and FEV-1/FVC of 84 percent. In order to warrant a rating in excess of 10 percent, the Veteran's disability must be manifested by a FEV-1 of 56 to 70 percent predicted, or FEV-1/FVC of 56 to 70 percent predicted, or daily inhalational or oral bronchodilator therapy, or inhalational anti-inflammatory medication. The Veteran's measured FEV-1 and FEV-1/FVC do not meet the criteria for a rating in excess of 10 percent. However, the Veteran has given credible statements, consistent with the examination findings, that he uses an inhaler as often as several times per day. Consequently, a rating of 30 percent is warranted. In order to warrant a rating in excess of 30 percent, the Veteran's disability must be manifested by FEV-1 of 40 to 55 percent predicted, or FEV-1FVC of 40 to 55 percent, or at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. The Veteran's measured FEV-1 and FEV-1/FVC do not meet the criteria for a rating in excess of 30 percent. There has also been no evidence that the Veteran has required at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. As the preponderance of the evidence is against the claim, reasonable doubt does not arise, and a higher initial rating for restrictive airway disease is denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Pursuant to 38 C.F.R. § 3.321(b)(1) (2012), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242, 244 (2008). If the evidence raises the question of entitlement to an extraschedular rating, 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. Initially, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors are marked interference with employment and frequent periods of hospitalization). The rating criteria fully contemplate the Veteran's disability as noted above, his symptomatology has consisted of shortness of breath and difficulty breathing. These symptoms are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of extraschedular rating is, therefore, not warranted. 38 C.F.R. § 3.321(b)(1). Total Disability Rating Based on Individual Unemployability (TDIU) The Court has held that entitlement to a TDIU is an element of all claims for a higher initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to a TDIU is raised when a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. See Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). The Veteran has not claimed that his service connected disabilities have prevented him from maintaining or obtaining gainful employment, and there is no other evidence to this effect. As there is no evidence of unemployability, the question of entitlement to a TDIU is not raised at this time under Roberson and Rice. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for pulmonary edema is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to an initial rating of 30 percent, but no greater than 30 percent, for restrictive airway disease is granted. REMAND Colon polyps The Board remanded this issue in May 2012, in part, so that the Veteran could undergo a VA examination. The Veteran underwent a VA examination in February 2013. However, the examiner failed to answer all of the questions posed in the remand. The Board is required to insure compliance with the remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). Cervical Spine The Veteran underwent a VA examination. The examiner diagnosed mild multilevel degenerative disc disease, and opined that the disability was less likely than not related to service. The examiner's rationale was that there was no documentation of arthritis when the Veteran was on active duty, and that it was not diagnosed until 2002 (14 years after service). A medical opinion that is based on the absence of documentation in service treatment records without considering a Veteran's reports is insufficient. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Sinus disability The Board remanded the claim so that the Veteran could undergo a VA examination. The examiner stated only that the Veteran "has [history] of sinusitis but no records to support chronic sinusitis. Last treatment for sinusitis was 2000." The history is inaccurate and did not consider the Veteran's reports. The Veteran; however, was treated by Dr. K.M. for allergic rhinitis in April 2004. In a June 2013 correspondence, he stated that he has had sinus issues since service, up to and including present day. He stated that he continues to take Claritin/Allegra/Allegra-D and Nasonex daily. Psychiatric disability The Board remanded the claim so that the Veteran could undergo a VA examination to determine if the Veteran had a psychiatric disability related to service. He underwent such an examination in December 2012, but the report seems to include conflicting reports as to whether he met the criteria for a diagnosis of PTSD or anxiety disorder. Further efforts are also needed to find evidence supporting the Veteran's stressor. Sexual dysfunction The Board remanded the claim so that the Veteran could undergo a VA examination and so that the Board could obtain a competent medical opinion. The Veteran underwent a VA examination, and the examiner opined that the Veteran's erectile dysfunction was not due to genitourinary conditions in the military. The examiner did not provide any rationale to support the opinion, and the in-service genitourinary conditions were never discussed. Tinnitus At VA examinations in January 2013 and February 2013, the examiner opined that it was at least as likely as not that the Veteran's tinnitus is a symptom of hearing loss. In an August 2013 statement, the Veteran raised the issue of entitlement to service connection for hearing loss. This issue is inextricably intertwined with the claim for service connection for tinnitus. The examiner also opined that the tinnitus was less likely as not due to noise exposure. The rationale was that the Veteran's in-service examinations did not reflect any threshold shifts from enlistment to separation. Examination reports of April 1996, April 1997, and February 1998, appear to show threshold shifts. . Skin disability The claim was previously remanded so that the Veteran could undergo a VA examination and the Board could obtain a competent medical examination. The examiner failed to render an opinion apparently because no skin disease was observed on examination, but it is unclear whether the examiner found evidence of a skin disease at any time during the appeal. Dizziness/vertigo The Veteran was afforded a VA examination in March 2013. The examiner noted dizziness and vertigo in 1998; and the Veteran believed that his current disability was due to chemical exposure that occurred during service. The examiner opined that the Veteran's vertigo/dizziness was less likely than not related to service. However, his rationale was limited in that it only ruled out that the disability was due to chemical exposure or due to a cervical spine disability. Gastrointestinal disability In his May 2013 notice of disagreement, the Veteran argued that the February 2013 VA examination was inadequate. He also argued that the VA discounted favorable evidence and his statements. In the Veteran's November 2010 claim, he stated that his gastrointestinal disability had been chronic since discharge from service, and that he had been treated since 1998. The first evidence of treatment in the record is a December 2002 report from Chesapeake Medical Associates. It lists the Veteran as a new patient who complained of burning on stomach since 1996. The February 2013 VA examiner did not consider the lay statements of the Veteran, the Board finds that a new VA examination is warranted. Left shoulder The Veteran underwent a VA examination in November 2012. He achieved 170 degrees of left shoulder flexion and abduction. After repetitive use testing, he reportedly had the same ranges of flexion and abduction. However, the examiner then stated that the Veteran has additional limitation of range of motion of the shoulder and arm following repetitive-use testing. Clarification is needed. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded a VA examination for the purpose of determining whether the Veteran's colon polyps are related to service. The claims file must be made available to the examiner for review in connection with the examination. The examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's colon polyps: (a) were malignant; (b) had their onset in service; (c) are related to in-service exposure to ionizing radiation; (d) are otherwise the result of a disease or injury in service; (e) are analogous to colon cancer (if not cancerous). The examiner should consider the documented in-service exposure to .074 rem of radiation (see October 2012 report from Naval Dosimetry Center). The examiner must provide reasons for each opinion. If the examiner is unable to provide an opinion without resort to speculation, the examiner must explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his in-service duties, his symptoms and history, and such reports, including those of a continuity of symptomatology, must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. The absence of supporting clinical records is not a sufficient reason, by itself, for rejecting his reports. If an opinion is received that the Veteran's colon polyps were malignant or the equivalent of colon cancer, refer the case to VA's Undersecretary for Benefits in order to obtain an advisory opinion from VA's Undersecretary for Health in accordance with 38 C.F.R. § 3.311(c) (2012). 2. The RO should attempt to verify the Veteran's in-service stressor (the death of his friend J.B. in June 1995). 3. The Veteran should be afforded a VA psychiatric examination for the purpose of determining whether a current psychiatric disability is related to service. The claims file must be made available to the examiner for review in connection with the examination. The examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran has any psychiatric disability (to include PTSD) that began during or is causally related to service. If the Veteran is diagnosed with PTSD, the examiner should specify the supporting stressor. The examiner must provide reasons for each opinion. If the examiner is unable to provide an opinion without resort to speculation, the examiner must explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his in-service duties, his symptoms and history, and such reports, including those of a continuity of symptomatology, must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. The absence of supporting clinical records is not a sufficient reason, by itself, for rejecting his reports. 4. Afford the Veteran a VA examination in order to determine whether the Veteran has dizziness/vertigo or a sinus disability related to service. Provide the examiner with the Veteran's claims file for review and ask the examiner to confirm in his report that he conducted such a review. Following a comprehensive evaluation, during which all indicated studies are conducted, the examiner should: a) indicate whether the Veteran has a disability manifested by dizziness and/or vertigo; b) opine whether such disability is at least as likely as not related to the Veteran's active service, including documented in-service dizziness; c) if not, indicate whether the Veteran's dizziness and/or vertigo is part of any cervical spine disorder as suggested in the service treatment records (the examiner should discuss the in-service statements by the Veteran that episodes occur when he turns his head); d) indicate whether the Veteran's dizziness and/or vertigo was caused or aggravated by the Veteran's service connected restrictive airway disease; e) state whether the Veteran has a current sinus disability, and if so, is it at least as likely as not (a 50 percent or greater probability) that it began during or is causally related to service, including the sinus conditions for which the Veteran was treated in August 1993 and June 1995, and including due to exposure to chemicals. f) provide a rationale, with specific references to the record, and the Veteran's reports, for the opinions expressed; and discuss why such is the case. The examiner is advised that the Veteran is competent to report injuries and in-service symptoms and that his reports must be considered in formulating the requested opinion. 5. The Veteran should be afforded a VA examination for the purpose of determining whether the Veteran has sexual dysfunction related to service. The claims file must be made available to the examiner for review in connection with the examination. The examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that any sexual dysfunction began during or is causally related to service, to include in-service genitourinary condition, and a psychiatric disability. The examiner is advised that the Veteran is competent to report injuries and symptoms and that his reports must be considered in formulating the requested opinion. The examiner must provide reasons for each opinion. 6. The Veteran should be afforded a VA examination for the purpose of determining whether the Veteran has skin disability related to service. The claims file must be made available to the examiner for review in connection with the examination. The examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's skin disability began during or is causally related to service. If the Veteran does not display any symptoms at the time of the examination, the examiner should indicate whether the Veteran has a current disability whose symptoms have temporarily subsided, or whether the Veteran's skin disability has resolved. In doing so, the examiner must discuss the Veteran's current complaints and recognize his contention that he continues to treat his symptoms. The examiner is advised that the Veteran is competent to report injuries and symptoms and that his reports must be considered in formulating the requested opinion. 7. The Veteran should be afforded a VA examination for the purpose of determining whether he has a gastrointestinal disability related to service. The claims file must be made available to the examiner for review in connection with the examination. The examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's disability began during or is causally related to service. The examiner must provide reasons for each opinion. If the examiner is unable to provide an opinion without resort to speculation, the examiner must explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his in-service duties, his symptoms and history, and such reports, including those of a continuity of symptomatology, must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. The absence of supporting clinical records is not a sufficient reason, by itself, for rejecting his reports. 8. The agency of original jurisdiction should adjudicate the claim for service connection for hearing loss disability. 9. The Veteran should be afforded a VA examination for the purpose of determining whether he has tinnitus related to service. It is imperative that the claims file be made available to the examiner for review in connection with the examination. The examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's tinnitus: a) began during or is causally related to service; b) was caused by or has been aggravated by the Veteran's vertigo/dizziness; c) was caused or aggravated by the Veteran's service connected restrictive airway disease. The examiner is advised that the Veteran is competent to report injuries and in-service symptoms and that his reports must be considered in formulating the requested opinion. 9. The Veteran should be schedule for a VA examination to determine whether he has a cervical spine disability related to service, and the current severity of his left shoulder disability. It is imperative that the claims file be made available to the examiner for review in connection with the examination. The examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that a cervical spine disability began during or is causally related to service. The examiner is advised that the Veteran is competent to report injuries and in-service symptoms and that his reports must be considered in formulating the requested opinion. Range of motion testing should be conducted, and, the examiner should report (in degrees) the point in range of motion testing where motion is limited by pain, weakness, fatigue, incoordination, and during flare-ups. 10. If any issue remains denied, issue a supplemental statement of the case, and return the record to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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). ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs