Citation Nr: 1341900 Decision Date: 12/18/13 Archive Date: 12/31/13 DOCKET NO. 04-23 697 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability. 3. Entitlement to service connection for an acquired psychiatric disability, to include major depressive disorder and posttraumatic stress disorder (PTSD). 4. Entitlement to a compensable rating for bilateral hearing loss. 5. Entitlement to a compensable rating for migraine headaches, prior to September 22, 2009. 6. Entitlement to a rating in excess of 10 percent for migraine headaches, beginning September 22, 2009. 7. Entitlement to a rating in excess of 30 percent for migraine headaches, beginning July 21, 2011. 8. Entitlement to a compensable initial rating for pseudofolliculitis barbae with scars prior to September 22, 2009. 9. Entitlement to an initial rating in excess of 10 for pseudofolliculitis barbae with scars from September 22, 2009. 10. Entitlement to an initial compensable rating for tonsillar hypertrophy. 11. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Scott Shoreman, Counsel INTRODUCTION The Veteran served on active duty from July 1967 to April 1971 and from July 1971 to January 1979. This case comes to the Board of Veterans' Appeals (Board) from various rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which adjudicated the issues on appeal. In December 2008, the Board remanded the claims of service connection for right and knee disabilities, major depressive disorder and PTSD. The Board also remanded the claim for a TDIU. In January 2011 the Board remanded the issues of service connection for right and left knee disabilities and an acquired psychiatric disability, increased evaluations for bilateral hearing loss, migraine headaches, pseudofolliculitis barbae with scars, and entitlement to a TDIU. The requested development has been completed on the issues service connection for right and left knee disabilities, increased evaluations for migraine headaches, and pseudofolliculitis barbae with scars. Additional development is needed on the issues of service connection for an acquired psychiatric disability, an increased evaluation for bilateral hearing loss, and entitlement to a TDIU. When this case was before the Board in December 2008, the Board reopened the Veteran's claim of service connection for PTSD and remanded that claim. Subsequent to the Board's December 2008 remand, the United States Court of Appeals for Veterans Claims (Court) decided Clemons v. Shinseki, 23 Vet. App. 1 (2009). The record shows that the Veteran has been diagnosed as having a host of psychiatric conditions, and consistent with Clemons, the Board finds that the scope of his claim of service connection for psychiatric disability should be construed based on the reasonable expectations of a non-expert, self-represented claimant, and the evidence developed during the claims process. Thus, in light of his contentions and the state of the record, the Board has identified the Veteran's de novo claim of service connection for psychiatric disability as set forth on the title page. Id. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran's representative included entitlement to a compensable evaluation for leg length discrepancy on the post-remand brief that was received by VA on September 18, 2013. The Veteran was notified of the Statement of the Case for this issue on July 10, 2013 for and did not perfect an appeal within 60 days. Therefore, this issue is not currently on appeal. The issue of whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for sleep apnea and entitlement to a compensable evaluation for leg length discrepancy have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issues of entitlement to service connection for an acquired psychiatric disability, to include major depressive disorder and PTSD, to an increased evaluation for bilateral hearing loss, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran's right knee disability was not present in service or until many years thereafter and is not related to service, to an incident of service origin, or to a service-connected disability or a causal or aggravation basis. 2. The preponderance of the evidence shows that the Veteran's left knee disability was not present in service or until many years thereafter and is not related to service, to an incident of service origin, or to a service-connected disability or a causal or aggravation basis. 3. Prior to July 21, 2011, the Veteran's migraine headaches occurred approximately weekly with some effect on activities of daily living. 4. From July 21, 2011, the Veteran's migraine headaches have been characterized by reactions to light and sound with nausea and prostrating effects. 5. The Veteran's pseudofolliculitis barbae with scars has been characterized by at least five percent but less than twenty percent of exposed skin area being affected. 6. The Veteran's tonsillar hypertrophy has not been characterized by hoarseness with inflammation of the vocal cords or mucus membrane. CONCLUSIONS OF LAW 1. A right knee disability was not incurred in or aggravated during service and was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2013). 2. A left knee disability was not incurred in or aggravated during service and was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2013). 3. The criteria for an evaluation of 10 percent, and no greater, for migraine headaches prior to September 22, 2009 have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.124a, Diagnostic Code 8100 (2013). 4. The criteria for an evaluation in excess of 10 percent for migraine headaches from September 22, 2009 through July 20, 2011 have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.124a, Diagnostic Code 8100 (2013). 5. The criteria for an evaluation in excess of 30 percent for migraine headaches from July 21, 2011 have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.124a, Diagnostic Code 8100 (2013). 6. The criteria for an initial evaluation of 10 percent, and not greater, for pseudofolliculitis barbae prior to September 22, 2009 have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.118, Diagnostic Codes 7813-7806 (2008 and 2013). 7. The criteria for an initial evaluation in excess of 10 percent for pseudofolliculitis barbae from to September 22, 2009 have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.118, Diagnostic Codes 7813-7806 (2008 and 2013). 8. The criteria for an initial compensable evaluation of 10 percent for tonsillar hypertrophy have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.97, Diagnostic Codes 6599-6516 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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, 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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 of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the 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. The claim for an increased ratings for service-connected pseudofolliculitis barbae and tonsillar hypertrophy arises from disagreement with the initial disability rating that was assigned 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); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Here, the VCAA duty to notify for the issue of service connection for knee disabilities was satisfied by way of a letter sent to the Veteran in March 2006 that fully addressed all notice elements and was sent prior to the initial RO decision in this matter. The letter informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. To the extent that additional notice sent in April 2009 and August 2009 VCAA notice came after the initial adjudication of the claims for increased ratings for migraine headaches, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The timing error was cured by content-complying VCAA notice after which the claim was readjudicated. The claim was last readjudicated by the supplemental statement of the case dated in January 2013. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). The Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. With respect to the Dingess requirements, the letters provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. Next, VA has a duty to assist a Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). 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). The claims file contains service treatment records, private treatment records, VA treatment records, and Social Security records. The July 2011 examinations for the knees, migraine headaches and tonsillar hypertrophy, September 2009 examination for pseudofolliculitis barbae are adequate for adjudicative purposes because the examiners supported their conclusions with rationales that can be weighed against the evidence of record. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran and his representative have not made the RO or the Board aware of any additional pertinent evidence that needs to be obtained in order to fairly decide the issues addressed in this decision, and has not argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced him in the adjudication of these issues. Given this, the Board may proceed to a decision on the merits. II. Analysis Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). In addition to the elements of direct service connection and presumptive service connection, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Disability ratings are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4 (2013). The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations. 38 U.S.C.A. § 1155 (2002). The disability must be viewed in relation to its history. 38 C.F.R. § 4.1 (2013). A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7 (2013). Where the appeal arises from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Thus, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). The evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is 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, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Service Connection for Right and Left Knee Disabilities The service treatment records show that in May 1970 the Veteran complained of right knee pain and the knee giving away. October 1971 treatment records state that in 1969 the Veteran injured his right knee jumping from a truck. He had recently begun driving trucks again and had reinjured his knee. In December 1971 the Veteran stated that he began to have pain in his right knee while running. There was no tenderness or pain on examination and the impression was a strain. At the December 1978 separation examination the lower extremities were normal. The post-service treatment records show that in November 1990 the Veteran complained of left knee pain and reported that he jumped down from a truck at work. A couple of days before the knee was so sore that he could hardly bend it. At December 2001 VA treatment the Veteran complained of knee pain. November 2002 x-rays of the knees showed minimal to moderate osteoarthritis. The Veteran complained of right knee pain at July 2004 treatment. At private treatment in March 2005 the Veteran reported an intermittent knee problem that was not actively bothering him. An examination of the knee was normal and the physician felt that the Veteran might have mild osteoarthritis with intermittent flare-ups. May 2005 x-rays of the right knee showed no bony, soft tissue or joint space abnormality. At April 2005 private treatment the Veteran complained of problems with his right knee. On examination there was mild tenderness along the medial joint line with minimal warmth and swelling. A June 2005 MRI of the right knee showed focal osteochondral defect overlying the lateral femoral condyle, mild osteoarthritis, and mild prepatellar and pretibial soft tissue swelling. The Veteran was issued a knee brace at June 2005 VA treatment. October 2005 VA treatment records state that the Veteran had chronic knee pain that he had had for years. The assessment was likely osteoarthritis and mild tendonitis. In January 2006 the Veteran wrote that during service he had to jump out of refueling trucks onto hard concrete surfaces year after year, which caused his knees "to deteriorate to the point of collapsing." The Veteran had a VA examination in June 2007 at which he said that he had several injuries while in the military. His job involved pulling on a long, heavy rubber hose that was used to refuel aircraft. The only post-service injury to the right knee that he could recall was slipping and twisting it in 1985. On examination there was mild tenderness to palpation of the right knee, subpatellar crepitus, and positive medial and lateral pain. The left knee had mild crepitus under the lateral edge of the patella and minimal distal femoral condyle and medial and lateral tenderness. The examiner diagnosed the Veteran with minimal osteoarthritic change and noted negligible evidence of impairment of the knee, and could not state an opinion on the relationship to service because of the impact of the Veteran's obesity on his knees. The Veteran had a VA examination in July 2011 at which he reported that during service he would frequently jump from a truck to the pavement. His right knee was more affected than the left and his knees had constant pain. The knees had gotten progressively worse since treatment and he took ibuprofen for them. He also occasionally used a cane. Upon an examination and review of x-ray imaging the examiner diagnosed the Veteran with degenerative joint disease of the knees and opined that it was not caused by active service and was not caused by, a result of, or aggravated by the service-connected leg length discrepancy or low back disability. The examiner felt that based on a review of the medical records, medical literature and clinical experience the Veteran had no left knee problems in service and right knee complaints in 1970 and 1971. There was absolutely no evidence of a chronic knee condition during service or for many years after separation from service. Furthermore, there was nothing to suggest that a leg length discrepancy would cause or aggravate degenerative joint disease in the knees or that degenerative disease of the spine causes or aggravates degenerative disease of the knees. It was much more likely that the degenerative joint disease of the knees was age related with some contribution from the Veteran's obesity. The VA examiner's July 2011 opinions are given probative value because he was informed of the pertinent facts, fully articulated the opinions, and supported the opinions with reasoned analyses. See Nieves-Rodriguez, 22 Vet. App. at 303-04; see also Stefl, 21 Vet. App. at 124. It is also noted that the post-service treatment records discussed above provide no indication that the Veteran's osteoarthritis of the knee is related to service or was caused by or aggravated by a service-connected disability. In light of the foregoing, the Board finds that the preponderance of the evidence is against entitlement to service connection for right and left knee disabilities. In reaching this determination, the Board acknowledges the Veteran's reports that his knee disabilities are related to the work he performed during service and to his service-connected leg length discrepancy and low back disability. In light of the July 2011 VA examiner's opinion, the Board finds the weight of the evidence preponderates against the claim. The Board concludes that the Veteran's account is less probative because, unlike the VA examiner, he does not offer a cogent rationale in support of his assessment. Therefore, probative value cannot be given to the Veteran's statements that his knee disabilities are related to service, including jumping from trucks, or to a service connected disability on a causation or aggravation basis. To the extent that the Veteran reports recurrent knee symptoms since service, the Board does not find his reports to be credible. The record does not show recurrent symptoms since service. The November 1990 treatment records indicate that the left knee complaints were due to a work injury, and the Veteran did not have complaints regarding the right knee. The record, including service treatment records, does not show any previous complaints related to the left knee. The post-service treatment records show complaints relating to the right knee beginning in December 2001, which was approximately 30 years after the in-service treatment related to the right knee. The record does not show ongoing symptoms between the in-service complaints and December 2001 regarding the right knee. In sum, the Board finds that the weight of the evidence is against the claim of service connection for right and left knee disabilities. As the preponderance of the evidence is against the claim, the Board must deny service connection and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Higher Rating for Migraine Headaches The Veteran is seeking a compensable evaluation prior to September 22, 2009, an evaluation in excess of 10 percent from September 22, 2009 through July 20, 2011, and an evaluation in excess of 30 percent from July 21, 2011 for migraine headaches. Diagnostic Code 8100 provides ratings for migraine headaches. Migraine headaches with less frequent attacks than the criteria for a 10 percent rating are rated as noncompensably (0 percent) disabling. Migraine headaches with characteristic prostrating attacks averaging one in 2 months over the last several months are rated 10 percent disabling. Migraine headaches with characteristic prostrating attacks occurring on an average once a month over last several months are rated 30 percent disabling. Migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability are rated 50 percent disabling. 38 C.F.R. § 4.124a. Private treatment records from September 2007 state that the Veteran was experiencing headaches. A private physician evaluated the Veteran in May 2008, and the Veteran stated that the headaches had been occurring for many years and were unchanged in frequency and severity. The Veteran wrote in December 2009 that the doctor misunderstood his complaints that the headaches were more severe and painful. He felt that his headaches were more frequent and were prostrating. The Veteran had a VA neurological examination in July 2008. The examiner did not feel that the Veteran's migraine headaches had significant effect on the Veteran's usual occupation and had a moderate effect on chores, shopping, exercise, sports, recreation, and travelling, and a mild effect on bathing. At October 2008 private treatment that Veteran reported moderate to severe headaches that had gotten worse. At the time of treatment he had light headaches with no migrainous features. The Veteran had another VA neurological examination on September 22, 2009 at which he reported having headaches on a weekly basis over the prior 12 months for which he took ibuprofen 800 mg. as needed. The attacks were not prostrating and ordinary activity was possible. The headaches lasted for hours. The examiner felt that the headaches had no significant effect on the Veteran's usual occupation and a moderate effect on some activities of daily living. A private physician wrote in July 2010 and December 2012 letters that the Veteran suffered from migraine headaches that had increased in severity. The Board notes that these letters do not provide detail on the disabling effects of the Veteran's headaches. The Veteran had a VA examination for migraine headaches on March 8, 2011. The examination report states that the attacks were not prostrating and that ordinary activity is possible. The Veteran got 10 to 15 headaches a month "for years and years and years and years." He said that his eyes got sensitive to bright lights and that he could not tell when a headache was coming on and that "the bad ones just came on like a lightning strike." The Veteran would rest for 30 to 45 minutes and then would feel better and could resume his usual activities and he took Ibuprofen on a daily basis. The Veteran had another VA examination on July 21, 2011 at which he reported that his headaches occur two to four times a month. They were located in the frontal region and were throbbing. He was sensitive to light and sound when he had headaches and would get nausea. The headaches lasted for two hours and the Veteran said that he was not functional during them. The course since onset had been stable and the Veteran took Fioricet as needed with a fair response. The examiner noted that most attacks were prostrating. The effect on usual occupation was increased absenteeism and more difficulty performing duties. The Veteran would have decreased concentration. The examiner felt that usual daily activities were severely affected due to headaches because the Veteran would have to lie down. The record shows that the Veteran was entitled to an evaluation of 10 percent, and no greater, prior to September 22, 2009. The October 2008 private treatment records described the Veteran's headaches as light with no migrainous features. However, the July 2008 VA examiner felt that the Veteran's headaches had a moderate effect on many activities of daily living. While the Veteran did not have characteristic prostrating attacks averaging one in two months, as required for a 10 percent evaluation, the Board finds that the effects of the headaches was equivalent to a 10 percent evaluation given how activities of daily living were impeded. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Board finds that the Veteran was not entitled to an evaluation greater than 10 percent for any period prior to July 20, 2011. Although the Veteran reported headaches on a weekly basis at the September 2009 VA examination, the examiner felt that ordinary activity was possible during the headaches. While the Veteran's December 2009 statement indicates that his headaches were prostrating, the Board does not find it credible that all of his headaches were prostrating during this period given that the September 2009 and March 2011 VA examiners specifically wrote that the headaches were not prostrating and that ordinary activities were possible during them. The treatment records and letters from the treating provider also do not indicate prostrating attacks. While the Veteran complained of sensitivity to bright lights during headaches at the March 2011 VA examination, by his own report he could resume normal activities within 30 to 40 minutes. Furthermore, the September 2009 and March 2011 examiners felt that ordinary activities were possible during the headaches. The Board also notes that the Veteran has not been entirely credible in his own descriptions of his headaches. At the March 2011 VA examination he reported 10 to 15 headaches a month for "years and years and years" while at the September 2009 VA examination he reported headaches on a weekly basis. Therefore, it is unclear how often the Veteran actually had headaches. Overall, the Veteran did not qualify for an evaluation of 30 percent, the next highest available, prior to July 21, 2011 because there were not characteristic prostrating attacks occurring on an average of once a month over the last several months or the equivalent. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. The preponderance of the evidence shows that the Veteran's most closely approximate the criteria for a 30 percent rating, and no more, from July 22, 2011. The July 2011 VA examiner felt that most of the Veteran's headaches were prostrating and the Veteran reported headaches two to four times a month during which he was sensitive to light and sound and would gat nauseous. While the July 2011 examination indicates more than one prostrating attack per month, the Veteran's headaches lasted for approximately two hours, which does qualify as prolonged, as contemplated by the rating criteria. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. Therefore, the Veteran does not qualify for a 50 percent evaluation, the next highest available, because the record does not show very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. See id. The preponderance of the evidence shows that the Veteran was entitled to an evaluation of 10 percent for migraine headaches prior to September 22, 2009. There is no doubt to be resolved regarding evaluations greater than 10 percent prior to July 21, 2011 and greater than 30 percent from July 21, 2011, and increased evaluations are not warranted. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 54-56. Higher Rating for Pseudofolliculitis Barbae The Veteran is seeking an initial compensable evaluation prior to September 22, 2009 and an evaluation in excess of 10 percent from September 22, 2009 for pseudofolliculitis barbae. Under the criteria in effect prior to October 23, 2008, Diagnostic Code 7800 provided ratings for disfigurement of the head, face, or neck. Note (1) to Diagnostic Code 7800 provides that the 8 characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, are: Scar is 5 or more inches (13 or more cm.) in length. Scar is at least one-quarter inch (0.6 cm.) wide at the widest part. Surface contour of scar is elevated or depressed on palpation. Scar is adherent to underlying tissue. Skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). Skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). Underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.). Skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Diagnostic Code 7800 provided that a skin disorder with one characteristic of disfigurement of the head, face, or neck is rated 10 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, is rated 30 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement, is rated 50 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement, is rated 80 percent disabling. Note (2) to Diagnostic Code 7800 provided that tissue loss of the auricle is to be rated under Diagnostic Code 6207 (loss of auricle), and anatomical loss of the eye under Diagnostic Code 6061 (anatomical loss of both eyes) or Diagnostic Code 6063 (anatomical loss of one eye), as appropriate. Note (3) provides that unretouched color photographs are to be taken into consideration when rating under these criteria. 38 C.F.R. § 4.118. Diagnostic Code 7803 provided a 10 percent rating for superficial unstable scars. Note (1) to Diagnostic Code 7803 provided that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provided that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic Code 7804 provided a 10 percent rating for superficial scars that are painful on examination. Note (1) to Diagnostic Code 7804 provided that a superficial scar is one not associated with underlying soft tissue damage. Note (2) provided that a 10-percent rating will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable rating. 38 C.F.R. § 4.118. Diagnostic Code 7804 also directs the rater to see 38 C.F.R. § 4.68 (amputation rule). 38 C.F.R. § 4.118. Diagnostic Code 7805 provided that other scars are to be rated on limitation of function of affected part. 38 C.F.R. § 4.118. Diagnostic Code 7806 provided ratings for dermatitis or eczema. Dermatitis or eczema is to be rated under either the criteria under Diagnostic Code 7806 or to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. Diagnostic Code 7806 provided that dermatitis or eczema that involves less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy is required during the past 12-month period, is rated noncompensably (0 percent) disabling. Dermatitis or eczema that involves at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period, is rated 10 percent disabling. Dermatitis or eczema that involves 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period, is rated 30 percent disabling. Dermatitis or eczema that involves more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period, is rated 60 percent disabling. 38 C.F.R. § 4.118. Diagnostic Code 7813 provides ratings for dermatophytosis (or ringworm) in various locations on the body, including the body (tinea corporis), the head (tinea capitis), the feet (tinea pedis), the beard (tinea barbae), the nails (tinea unguium), and the inguinal area, also known as jock itch (tinea cruris). Diagnostic Code 7813 provides that dermatophysosis is to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. 38 C.F.R. § 4.118. On October 23, 2008, during the course of the present appeal, Diagnostic Codes 7800, 7801, 7802, 7803, 7804, and 7805 were revised. These revisions are applicable only to claims filed on or after October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). A Veteran previously evaluated under the previous criteria may request review under the revised criteria. Id. The effective date of any award under the new criteria cannot be earlier than October 23, 2008, the date on which the revised criteria went into effect. Id. The RO reviewed the Veteran's claim under both the old and new criteria and the Veteran has implicitly asked for review under the new criteria. Therefore, the Board will review the claim under the old and new criteria since it cannot prejudice the Veteran to do so. Under the criteria effective as of October 23, 2008, in addition to the former criteria under Diagnostic Code 7800 listed above, Notes (4) and (5) were added. Disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, are evaluated under the appropriate diagnostic code(s) and combined under section 4.25 with the evaluation assigned under this diagnostic code. 38 C.F.R. § 4.118, DC 7800, Note (4) (2013). Furthermore, the characteristic(s) of disfigurement may be caused by one scar or by multiple scars, and need not be caused by a single scar in order to assign a particular evaluation. 38 C.F.R. § 4.118, DC 7800, Note (5) (2013). Under the criteria of revised DC 7801, burn scars or scars due to other causes, not of the head face, or neck, that are deep and nonlinear, with an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrant a 10 percent rating. A 20 percent rating requires an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A 30 percent rating requires an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.). A 40 percent rating requires an area or areas of 144 square inches (929 sq. cm.) or greater. A qualifying scar is one that is nonlinear and deep, and is not located on the head, face, or neck. 38 C.F.R. § 4.118 (2010). Note (1) to Diagnostic Code 7801 provides that a deep scar is one associated with underlying tissue damage. Note (2) provides that if multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Combine the separate evaluations under § 4.25. Qualifying scars are scars that are nonlinear, deep, and are not located on the head, face, or neck. 38 C.F.R. § 4.118. Under the criteria of revised Diagnostic Code 7804, one or two scars that are unstable or painful on examination warrant a 10 percent rating. A 20 percent rating requires three or four scars that are unstable or painful. A 30 percent rating requires five or more scars that are unstable or painful. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. If one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is based on the total number of unstable or painful scars. Scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an additional evaluation under this Diagnostic Code, when applicable. 38 C.F.R. § 4.118. Under the criteria of revised DC 7805, any disabling effects of other scars (including linear scars), and other effects of scars evaluated under DCs 7800, 7801, 7802, and 7804 not considered in a rating provided under DCs 7800-7804 are to be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118. A private physician wrote in May 2006 that the Veteran had pseudofolliculitis barbae with some scarring and post inflammatory pigment alterations. The Veteran's beard area had many hyperpigmented follicular papules and macules and many ingrown hairs. The physician also noted that there was some scarring with post inflammatory alteration. August 2006 VA treatment records state that the Veteran did not need a dermatology appointment for pseudofolliculitis barbae because it had resolved on his last visit to the clinic. The Veteran had a VA examination for his skin in June 2007. He said that the current treatment for pseudofolliculitis barbae was to use clippers on his beard and to not shave. The Veteran did not report significant flare-ups of facial irritation, bleeding, or cystic disease such as in grown hairs or subdermal areas of pus. The examiner estimated that 40 percent of exposed skin was affected and 2 to 2.5 percent of total body area. There was no major scarring or disfigurement and no visible papules, pustules, comedones, or other types of loculated cystic lesions, nodules or infections. In addition, there was no scarring alopecia, alopecia areata, or evidence of hyperhidrosis. The examiner felt that there was no evidence of active pseudofolliculitis barbae for "quite some time" based on the lack of significant lesions. The Veteran had a VA examination on September 22, 2009 at which he reported a burning feeling due to pseudofolliculitis barbae. There was no current treatment and had not been any in the past 12 months. On examination there were three small papules on the beard area and hyperpigmentation from the right mid-cheek to the left mid-cheek, including the chin and neck. Other than the hyperpigmentation there were no scars appreciable in the hair bearing areas of the face. The percent of total body area affected was less than 5 percent and the percentage of exposed area affected was 10 percent. The examiner felt there was no disfigurement or functional limitation due to the skin condition and that the pseudofolliculitis barbae did not preclude physical or sedentary employment. The Board finds that the Veteran is entitled to an evaluation of 10 percent, and no greater, for pseudofolliculitis barbae prior to September 22, 2009. The May 2006 report from the private physician indicates that exposed areas on the Veteran's face were affected by pseudofolliculitis barbae. Therefore, the Veteran qualified for a 10 percent evaluation because at least 5 percent but less than 20 percent of exposed areas were affected. See 38 C.F.R. § 4.118, Diagnostic Code 7806 (2008 and 2013). The record does not show that the Veteran has qualified for an evaluation in excess of 10 percent for pseudofolliculitis barbae at any time during the period on appeal because at least 20 percent of exposed areas or the entire body were affected. See 38 C.F.R. § 4.118, Diagnostic Code 7806 (2008 and 2013). Furthermore, the record does not show that the Veteran has required systemic therapy for pseudofolliculitis barbae. See id. While the May 2006 private physician did not indicate the percentage of the exposed or total area that was affected, August 2006 treatment records indicate that pseudofolliculitis barbae had resolved. The June 2007 VA examiner estimated that 40 percent of exposed area was affected. However, the examination report indicates that there was not active pseudofolliculitis barbae and that the Veteran was not symptomatic. Therefore, the examination report seems to be estimating the percentage of exposed area that could potentially be affected, not the percentage that actually was affected at that time. The September 2009 VA examiner estimated that less than 5 percent of total body area and 10 percent of exposed area was affected. The Veteran also has not qualified for an evaluation in excess of 10 percent under Diagnostic Code 7800 for disfigurement of the head, face or neck. The September 2009 examination report indicates hyperpigmentation. It is not clear whether it meets the requirement to be a characteristic of disfigurement by exceeding an area of six square inches. See 38 C.F.R. § 4.118, Diagnostic Code 7800, Note (1) (2008 and 2013). However, the Veteran has not met the criteria for having other characteristics of disfigurement and the records does not indicate gross distortion or asymmetry of one feature or paired features. See id. The record also does not show other disabling effects from pseudofolliculitis barbae or that there could be additional characteristics of disfigurement from multiple scars or the total effect of pseudofolliculitis barbae. See 38 C.F.R. § 4.118, Diagnostic Code 7800, Notes (4) and (5). Therefore, he cannot qualify for an evaluation of 30 percent, the next highest available after 10 percent, under Diagnostic Code 7800. See 38 C.F.R. § 4.118 (2008 and 2013). The preponderance of the evidence shows that the Veteran was entitled to an initial evaluation of 10 percent for pseudofolliculitis barbae prior to September 22, 2009. There is no doubt to be resolved regarding an evaluation greater than 10 percent for the entire period of appeal, and additional increased evaluations are not warranted. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 54-56. Higher Rating for Tonsillar Hypertrophy The Veteran is seeking an initial compensable evaluation for tonsillar hypertrophy. The RO has evaluated the Veteran's disability by analogy under 38 C.F.R. § 4.97, Diagnostic Code 6516, pertaining to laryngitis. Under this Diagnostic Code, a 10 percent evaluation contemplates hoarseness, with inflammation of cords or mucous membrane. A maximum 30 percent evaluation is assigned for hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. At August 2004 private treatment for a sore throat there was no radiographic evidence of an airway obstruction. June 2007 private treatment notes indicate that the Veteran was diagnosed with hypertrophy of the tonsils only. On examination the tonsils were greater than normal in size. The Veteran had a VA examination in July 2011 at which it was noted that the course since onset was improved and that there was no current treatment for the throat. The examiner noted that the Veteran had enlarged tonsils and a right tonsillar cyst of unclear clinical significance. The record shows that the Veteran has enlarged tonsils. However, the record does not show hoarseness, inflammation of the cords or mucus membrane. Furthermore, the record does not show that any ongoing treatment has been required for tonsillar hypertrophy. Therefore, the Veteran does not qualify for a 10 percent evaluation for tonsillar hypertrophy. See 38 C.F.R. § 4.97, Diagnostic Codes 6599-6516. Other Diagnostic Codes regarding diseases of the nose and throat are not applicable for tonsillar hypertrophy. See 38 C.F.R. § 4.97, Diagnostic Codes 6502 - 6515 and 6518 - 6524. The preponderance of the evidence is against the claim. There is no doubt to be resolved, and an evaluation in excess of 10 percent for tonsillar hypertrophy is not warranted. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 54-56. Other Considerations In light of the holding in Fenderson and Hart, the Board has considered whether the Veteran is entitled to "staged" ratings for his service-connected migraine headaches, pseudofolliculitis barbae, and tonsillar hypertrophy, as the Court indicated can be done in this type of case. Based upon the record, we find that at no time during the claims period have the disabilities on appeal been more disabling than as currently rated under the present decision of the Board. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's migraine headaches, pseudofolliculitis barbae, and tonsillar hypertrophy, in that the manifestations of these service-connected disabilities are contemplated in the rating criteria. No exceptional or unusual disability picture is shown by the disabilities. The rating criteria are therefore adequate to evaluate these service-connected disabilities and referral for consideration of extraschedular rating is not warranted. ORDER Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. Entitlement to a rating of 10 percent, and no greater, for migraine headaches prior to September 22, 2009 is granted. Entitlement to a rating in excess of 10 percent for migraine headaches from September 22, 2009 through July 20, 2011 is denied. Entitlement to a rating in excess of 30 percent for migraine headaches from July 21, 2011 is denied. Entitlement to an initial rating of 10 percent, and no greater, for pseudofolliculitis barbae prior to September 22, 2009 is granted. Entitlement to an initial rating in excess of 10 percent for pseudofolliculitis barbae from September 22, 2009 is denied. Entitlement to an initial compensable rating for tonsillar hypertrophy is denied. REMAND The Veteran had a VA examination in September 2009. On the audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 50 35 50 40 LEFT 25 45 40 55 60 Speech audiometry revealed speech recognition ability of 76 percent in the right ear and of 62 percent in the left ear. The examiner stated that the speech recognition scores were most likely unreliable and were unsuitable for rating purposes because they were inconsistent with the observed communication abilities and with past testing. The Veteran was diagnosed with bilateral sensorineural hearing loss. The examiner felt that the hearing loss would have significant effects on the Veteran's occupational activities because of the reported difficulty hearing speech, hearing when people were behind him, and localizing sound. Furthermore, the examiner did not feel that the hearing loss would render the Veteran unable to secure or follow of substantially gainful occupation. The Veteran had a private audiological evaluation in October 2009. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 45 60 66 n/a 55 LEFT 45 55 55 65 65 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 88 percent in the left ear at 80 decibels. The private audiologist wrote in a December 2009 statement that the Veteran was a good candidate for hearing aids. It was also noted that a comparison of the results to October 2006 testing suggested that the hearing loss was progressive in nature. The Veteran had another VA examination in July 2011. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 40 50 45 55 50 LEFT 40 50 50 60 60 Speech recognition scores could not be measured because of test results that were not consistent with demonstrated communication ability. The examiner noted that the hearing loss would cause some communication difficulty in work situations, particularly in difficult listening situations such as the presence of background noises. Hearing aids would help in overcoming this but observed, unaided communication ability in a quiet situation with the Veteran not facing the speaker was judged to be good. The Veteran had private audiology testing in September 2013. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 65 60 65 n/a 65 LEFT 65 60 65 n/a 65 The September 2013 private audiology testing indicates that the degree of hearing loss may have worsened since the last VA examination in July 2011. As such, VA is required to afford him a contemporaneous VA examination to assess the current nature, extent and severity of his bilateral hearing loss. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Thus, the Board has no discretion and must remand this claim. The Veteran is seeking service connection for an acquired psychiatric disability, and the Board remanded this issue in January 2011 in order for the Veteran to be scheduled for a VA examination, which took place in July 2011. The examiner diagnosed him with depressive disorder, NOS and felt that the Veteran did not meet the criteria for PTSD. In regards to depression, the examiner opined that it was less likely related to or had its onset during active duty or was caused/aggravated by service-connected disabilities. The examiner did not provide a rationale for the opinion, and therefore it is not sufficient for adjudication. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (A medical opinion must support its conclusion with an analysis the Board can consider and weigh against other evidence in the record.). Therefore, an addendum to the opinion must be obtained before the claim can be decided on the merits. With regard to the issue of entitlement to a TDIU, the resolution of the Veteran's claims that are in appellate status may impact whether the Veteran satisfies the schedular (numerical) requirements for a TDIU rating, as set forth in 38 C.F.R. § 4.16(a). As such, the claims are inextricably intertwined and must be considered together, and a decision by the Board on the Veteran's TDIU claim would, at this point, be premature. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Request that the Veteran provide sufficient information, and, if necessary, authorization, to obtain any additional evidence, not already of record, which pertains to the claims for an increased evaluation for bilateral hearing loss, service connection for an acquired psychiatric disability, and entitlement to a TDIU. Document all unsuccessful attempts to obtain such records. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge of the nature, extent and severity of his bilateral hearing loss, who have first-hand knowledge, and/or were contemporaneously informed his acquired psychiatric disability, and the impact of his service-connected disabilities on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. After associating any pertinent, outstanding records with the claims folder, afford the Veteran a VA audiological examination to determine the current severity of his bilateral hearing loss disability. All necessary testing should be administered, with all relevant findings reported. In addition to objective test results, the examiner should fully describe the functional effects caused by the hearing disability in his or her final report and the impact of such on his employability. In addressing the functional effects of the Veteran's hearing loss on his occupational functioning generally, the examiner should consider his employment history, educational background, and day-to-day functioning in relation to his bilateral hearing loss. All findings and conclusions should be set forth in a legible report. 4. After associating any pertinent, outstanding records with the claims folder, arrange for the July 2011 examiner who conducted the PTSD examination to prepare an addendum to his report. If he is not available, another provider should prepare the addendum. After a review of the claims file, to include service and post-service medical records, the examiner must opine as to whether it is at least as likely as not that depressive disorder NOS is related to or had its onset in service. The examiner is also asked to provide an opinion as whether it is at least as likely as not that depressive disorder NOS was caused or aggravated by a service-connected disability, to include the aggregate impact of his service-connected disabilities. A complete rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. Schedule the Veteran for a VA examination, to be conducted, if possible, by a vocational specialist, to ascertain the impact of the Veteran's service-connected disabilities on his ability to obtain and maintain substantially gainful employment. The examiner should review the claims file and conduct any tests deemed necessary. Thereafter, the VA examiner is requested to offer an opinion as to whether the Veteran's service-connected disabilities, to include in the aggregate, without consideration of the Veteran's age or non-service-connected disabilities, render him unable to secure or maintain a substantially gainful occupation, in light of his education, training and work history. All findings and conclusions should be set forth in a legible report. 6. Then readjudicate the appeal. If the benefits sought on appeal are not granted in full, issue the Veteran and his representative a supplemental statement of the case and provide the Veteran an opportunity to respond. 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). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs