Citation Nr: 1420175 Decision Date: 05/06/14 Archive Date: 05/16/14 DOCKET NO. 11-15 346 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for hypertension, as due to service-connected posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for erectile dysfunction, as due to service-connected PTSD. 4. Entitlement to service connection for sterility (claimed as low sperm count), as due to herbicide exposure. 5. Entitlement to a higher (compensable) initial rating (evaluation) prior to June 20, 2013, and in excess of 10 percent, thereafter, for service-connected gastroesophageal reflux disease (GERD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD L.M. Yasui, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from May 1968 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2009, January 2011, and February 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In January 2014, the Veteran testified in a Videoconference Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is located in the Veteran's file on the "Virtual VA" system. After reviewing the contentions and evidence of record, the Board finds that the issues on appeal are more accurately stated as listed on the title page of this decision. In this regard, the Veteran has claimed that he has a low sperm count and as a result, he and his wife have been unable to have children. As such, the Board recharacterized the issue on appeal as a claim for service connection for sterility to reflect the Veteran's contentions. In evaluating this case, the Board has not only reviewed the physical claims file, but has also reviewed the file on the Virtual VA system to ensure a complete assessment of the evidence. In a November 2009 rating decision, the RO denied service connection for PTSD with anxiety and depression. In a December 2009 notice of disagreement, the Veteran initiated an appeal as to that issue. In April 2011, the RO fully granted service connection for PTSD with anxiety and depression; therefore, that issue is not in appellate status, and is not before the Board. The issues of service connection for erectile dysfunction and sterility are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran was exposed to loud sounds (acoustic trauma) in service. 2. The Veteran has a current bilateral hearing loss disability for VA compensation purposes. 3. The Veteran's current bilateral hearing loss was incurred in service. 4. The Veteran has a current diagnosis of hypertension. 5. The Veteran is service connected for PTSD. 6. Hypertension is proximately due to the service-connected PTSD. 7. Prior to June 20, 2013, the Veteran's GERD was manifested by no more than epigastric distress and pyrosis, which was not productive of considerable impairment or health. 8. From June 20, 2010, forward, the Veteran's GERD manifested in epigastric distress, pyrosis, nausea, and regurgitation, which was not productive of considerable impairment or health. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for bilateral hearing loss have been met. 38 U.S.C.A. §§ 1110, 1154, 5103, 5103A, 5107, (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for hypertension have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103(a), 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2013). 3. Resolving all reasonable doubt in the Veteran's favor, prior to June 20, 2013, the criteria for a 10 percent evaluation for GERD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.20, 4.114, Diagnostic Code 7346 (2013). 4. For the entire rating period, the criteria for an initial evaluation in excess of 10 percent for GERD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.20, 4.114, Diagnostic Code 7346 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2013). The claims of service connection for bilateral hearing loss and hypertension have been considered with respect to VA's duties to notify and assist. Given the favorable outcomes adjudicated herein, no conceivable prejudice to the Veteran could result from this decision, and further explanation of how VA has fulfilled the duties to notify and assist is not necessary. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). With respect to the appeal for a higher initial rating prior to June 20, 2013, and in excess of 10 percent, thereafter, for service-connected GERD, the appeal decided in this decision arises from the Veteran's disagreement with the initial rating following the grant of service connection for GERD. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United States Court of Appeals for Veterans Claims (Court) have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App.112 (2007). With regard to the duty to assist, the Veteran's service treatment records and pertinent post-service treatment records, including private and VA treatment reports, have been secured. The RO arranged for VA examinations in February 2011 and June 2013. These examinations, taken together, are found to be adequate for rating purposes of the issues. The examiners reviewed the Veteran's medical history and complaints, made clinical observations, and rendered opinions regarding the severity of the disability. See Barr v. Nicholson, 21 Vet. App. (2007) (finding that VA must provide an examination that is adequate for rating purposes). As such, VA has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Hence, no further notice or assistance is required to fulfill VA's duty to assist the Veteran in the development of the claim. Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In this case, sensorineural hearing loss (as an organic disease of the nervous system) and hypertension (as a cardiovascular-renal disease) are "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions based on "chronic" in-service symptoms and "continuous" post-service symptoms under 38 C.F.R. § 3.303(b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as sensorineural hearing loss and hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. The Court has held that a veteran may establish the required nexus between his current hearing loss disability and his term of military service if he can show that his hearing loss disability resulted from acoustic trauma. Godfrey v. Derwinski, 2 Vet. App. 352 (1992). Hearing loss (also referred to as hearing "impairment") will be considered a disability for VA disability compensation purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least 3 of the frequencies 500, 1000, 2000, 3000 or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In evaluating claims of service connection for hearing loss, the threshold for normal hearing is from 0 to 20 decibels, with higher threshold levels indicating some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. a 303. Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau at 1372). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the Veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Combat Rule In the case of a veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation. See 38 U.S.C.A. § 1154(b); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The standard used to determine whether a veteran engaged in combat with the enemy is reasonable doubt, which is to be resolved in a veteran's favor. See VAOPGCPREC 12-99. The provisions of 38 U.S.C.A. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine, 9 Vet. App. at 522-23. The provisions of 38 U.S.C.A. § 1154(b) do not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). In this case, the evidence supports the finding that the Veteran engaged in combat. In particular, the Veteran's service records document his involvement in combat during the Vietnam War, as evidenced by receipt of the Vietnam Gallantry Cross with Palm. The Republic of Vietnam awarded the Vietnam Gallantry Cross with Palm to units for valorous combat achievements. See Manual of Military Decorations and Awards (Department of Defense Manual 1348.33-V3, November 2010). Based on this evidence, the Board finds that the Veteran engaged in combat with the enemy during service, and the combat rule is applicable. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Service Connection for Bilateral Hearing Loss The Veteran asserts that his current bilateral hearing loss is the result of noise exposure while in active service. He has reported noise exposure during combat, and that he experienced ear infections during service. After a review of all the evidence, the Board finds that the Veteran sustained acoustic trauma during service, including during combat. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). In the December 2010 VA audiology examination, the Veteran reported that during service he was exposed to loud noise (acoustic trauma) while in Vietnam. He also reported having recurrent ear infections in both ears that first began in service. Post-service evidence reflects a current bilateral hearing loss for VA purposes, which was first diagnosed at the December 2010 VA audiology examination. Therefore, a current hearing loss disability shown. 38 C.F.R. § 3.385. The Board finds that the evidence is in equipoise on the question of whether the Veteran's current bilateral hearing loss disability is related to the in-service loud noise exposure. On the question of nexus to service, the December 2010 VA examiner opined that the hearing loss is not caused by or a result of military noise exposure. The VA examiner relied on the factual assumption that the Veteran had hearing within normal limits at both enlistment and separation. The Board finds the April 2010 VA examiner's opinion to be legally inadequate in its reliance only on the entrance and separation audiometric examinations and findings that showed normal hearing at service enlistment and separation as a basis for the opinion. A claimant may establish entitlement to service connection for hearing loss even if there is no showing of hearing loss in service or for years thereafter, so long as evidence demonstrates a medical relationship between the in-service noise exposure and the current disability. Hensley, 5 Vet. App. at 160. There is no other adequate medical nexus opinion that addresses the etiology of the Veteran's bilateral hearing loss; as such, the Board must look to the remaining evidence of record to determine whether service connection is warranted. 38 C.F.R. § 3.303(d) (service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service). Here, the Veteran was diagnosed with bilateral hearing loss after discharge. See Hensley at 160. This diagnosis coupled with the evidence pertinent to service, specifically, the Veteran's competent and credible statements indicating in-service acoustic trauma, are evidence supportive of the Veteran's claim. Significantly, as noted above, the December 2010 VA examiner diagnosed bilateral recurrent tinnitus and opined that the tinnitus symptoms were at least as likely as not the result of military service. The Board finds this opinion regarding tinnitus is also supportive of service connection for bilateral hearing loss. The December 2010 opinion establishes that the Veteran experienced acoustic trauma and that he sustained a current disability of the ear as a result of that trauma. Indeed, the Veteran's hearing loss disability (identified as sensorineural hearing loss) is of the type and configuration that is consistent with in-service noise exposure given the Veteran's history and current diagnosis of tinnitus. Sensorineural hearing loss is defined as "that due to a lesion in either the cochlea (sensory mechanism of the ear), the vestibulocochlear nerve, the central neural pathways, or a combination of these structures. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 836 (31st Ed. 2007); see also 38 C.F.R. § 20.903(b)(2) (notice to the appellant is not required if the Board uses a recognized medical treatise or medical dictionary for the limited purpose of defining a medical term and that definition is not material to the Board's disposition of the appeal). While the Veteran's bilateral hearing loss did not manifest within a year after discharge from service or for years after separation, presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. See 38 C.F.R. § 3.303(d). In this case, consideration of the totality of the evidence of record establishes that the Veteran's bilateral hearing loss was incurred in service, that is, that the hearing loss had its onset in service even though such was not diagnosed until years later. Id. The evidence shows acoustic trauma that was sufficient to cause nerve damage to the ears, as recognized by the grant of service connection for tinnitus based on that loud noise exposure. The evidence also reflects diagnosis of sensorineural hearing loss, which is consistent with sensorineural (nerve) damage. In this case, the only potential cause of nerve damage identified was the in-service event and injury of trauma. The nature of the diagnosis of sensorineural hearing loss recognizes the nerve involvement. There is no adequate competent medical opinion to weight against the claim, despite the fact an attempt was made to obtain an opinion on the question of nexus to service. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for direct service connection for bilateral hearing loss, as incurred in service, have been met. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Hypertension The Veteran contends that hypertension is secondary to the service-connected PTSD. As stated above, to prevail on the issue of secondary service causation, the record must show competent evidence of (1) a current disability, (2) a service-connected disability, and (3) a connection between the current disability and the service-connected disability. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 16-17. After a review of all the evidence, the Board first finds that the evidence shows a current disability of hypertension. Post-service treatment records reveal the Veteran was first diagnosed with hypertension in February 2003 with continuing treatment in July 2007. The Board next finds that the weight of the competent evidence is at least in relative equipoise on the question of whether the Veteran's hypertension is proximately due to the service-connected PTSD. In this regard, an April 2011 RO rating decision granted service connection for PTSD with anxiety and depression. In support of the claim, the Veteran's treating physician, Dr. T.S., submitted a letter and opined that the hypertension is directly related to PTSD. He opined that the degree of hazardous exposure endured by the Veteran during service has had a significant effect on both his mental and physical health. The Board finds that Dr. T.S.'s medical opinion regarding the etiology of the Veteran's hypertension to be probative. Dr. T.S.'s opinion is competent and probative medical evidence because it is factually accurate, as it appears he had knowledge of the relevant evidence in this case, relied on accurate facts, and gave a fully articulated opinion that is supported by a sound, albeit brief, reasoning. There is no other competent medical opinion of record against the claim that directly addresses the etiology of the Veteran's hypertension. For these reasons and resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for hypertension, as secondary to the service-connected PTSD, have been met. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Disability Rating Criteria Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2013). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. 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. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). Here, the Board will evaluate the issue as an appeal for higher evaluations of the original awards. In such cases, 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. Id. Analysis of a Higher Initial Rating for Service-Connected GERD In the February 2011 rating decision on appeal, service connection for GERD was granted, and an initial, noncompensable (zero percent) disability rating was assigned, effective October 8, 2009, the day the claim was received. The Veteran submitted a notice of disagreement with the initial rating assigned, contending that the severity of the GERD symptoms warranted a higher initial rating. In an August 2013 rating decision, the RO granted a higher initial disability rating of 10 percent for the period (or "stage") of rating starting June 20, 2013, which was the date of the VA examination. GERD is not among the listed conditions in the Rating Schedule. When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. The Board finds that GERD is most closely analogous to a hiatal hernia in terms of symptomatology and resulting disability pictures. A 10 percent evaluation is warranted for a hiatal hernia with two or more of the symptoms required for a 30 percent evaluation which are of lesser severity than is required for a 30 percent evaluation. A 30 percent evaluation requires persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation accompanied by substernal, arm, or shoulder pain which is productive of considerable impairment of health. A 60 percent evaluation requires symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Disability evaluations assigned under Diagnostic Codes 7301 to 7329 (inclusive), 7331, 7342, and 7345 to 7348 (inclusive) will not be combined with each other. Instead, a single evaluation will be assigned under the diagnostic code which reflects the Veteran's predominant disability picture with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114, Diagnostic Code 7346. During the February 2011 VA examination, the Veteran reported having heartburn (pyrosis) and burning epigastric pain. He also reported taking Prevacid daily and Pepcid intermittently. He had no nausea or vomiting, and no significant weight loss or malnutrition. In the June 2013 VA examination report, the examiner noted that the Veteran takes continuous medication, specifically Prilosec, for the diagnosed stomach condition. At that time, the Veteran reported abdominal pain that was only partially relieved by standard ulcer therapy, mild nausea, and mild vomiting. The Veteran did not have incapacitating episodes or a functional impact due to signs or symptoms of the stomach condition. During the January 2014 Videoconference Board hearing, the Veteran testified that he experienced the same symptoms, specifically stomach pain, vomiting, and heartburn, for the entire period on appeal, but that they increased in severity over time. See Hearing Transcript at 6-7. The Board has reviewed the probative evidence of record including the Veteran's testimony on appeal. Prior to June 20, 2013, the Veteran's GERD was manifested by no more than epigastric distress and pyrosis, which was not productive of considerable impairment or health. Resolving reasonable doubt in the Veteran's favor, such findings merit assignment of a 10 percent evaluation under the provisions of Diagnostic Code 7346. The evidence shows that, from June 20, 2013, the Veteran's GERD manifested in epigastric distress, pyrosis, nausea, and regurgitation, which was not productive of considerable impairment or health. Throughout the appeal period, the Veteran's GERD symptoms were controlled by various medications, including Prevacid, Pepcid, and Prilosec. In the absence of any subjective or objective findings such as substernal, arm, or shoulder pain and a considerable impairment of health associated with the Veteran's GERD, the Board finds that an evaluation in excess of 10 percent is not warranted at any point during the period on appeal. Fenderson, 12 Vet. App. at 126. Extraschedular Consideration The Board has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2013); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. The Board finds that the symptomatology and impairment caused by the Veteran's service-connected GERD are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The rating criteria found in Diagnostic Code 7346 contemplate the Veteran's symptoms and impairment, and reasonably describe the GERD disability level and symptomatology, specifically, epigastric pain, nausea, regurgitation, and pyrosis (heartburn). 38 C.F.R. § 4.114, Diagnostic Code 7346. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran regarding the service-connected GERD are specifically contemplated by the criteria discussed above, including the effect of the Veteran's symptoms on his occupation and daily life. In the absence of exceptional factors associated with GERD, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Moreover, the Board has considered whether the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) was reasonably raised by the record in this case. Neither the Veteran nor the evidence suggests unemployability due to service-connected disabilities. Rice v. Shinseki, 22 Vet. App. 447 (2009). Indeed, the February 2011 VA examination report indicated that the Veteran is employed, and the June 2013 examiner indicated that the service-connected GERD does not impact the Veteran's ability to work; therefore, as the issue of a TDIU is not reasonably raised by the record, it is not part of the rating appeal. ORDER Service connection for bilateral hearing loss is granted. Service connection for hypertension is granted. An initial 10 percent rating for service-connected GERD, for the rating period prior to June 20, 2013, is granted; and an initial rating in excess of 10 percent for any period is denied. REMAND Service Connection for E.D. and Sterility A remand is required in this case to ensure that there is a complete record upon which to decide the Veteran's claims of service connection for erectile dysfunction and sterility. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002); 38 C.F.R. § 3.159(c), (d) (2013). The Board finds that a VA examination is necessary to assist in determining the nature and etiology of any current erectile dysfunction and sterility. VA must afford a veteran a medical examination or obtain a medical opinion when necessary to make a decision on a claim. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Court in McLendon v. Nicholson, 20 Vet. App. 79 (2006), provided further guidance, outlining that VA must provide a medical examination when there is: (1) competent evidence of a current disability or persistent recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA Secretary to make a decision on the claim. With respect to the need for an indication that a veteran's current disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, the Court stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and a veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus, but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology to include symptoms capable of lay observation. McLendon, 20 Vet. App. at 83. In this case, the Veteran has not been afforded a VA examination for the claimed erectile dysfunction and sterility. A private laboratory report from December 1987 indicated that the Veteran had low sperm count and slightly sluggish motility. In March 2014, the Veteran's private physician, Dr. T.S., opined that the Veteran has low sperm count likely related to Agent Orange exposure. In this regard, with consideration of the Veteran's personnel records and combat service, exposure to herbicides is presumed. 38 U.S.C.A. § 1154(b). Dr. T.S., however, did not indicate whether the low sperm count resulted in sterility or if the Veteran has a current disability of sterility. In addition, while the Veteran is competent to report the symptoms of erectile dysfunction, the record is unclear as to whether the Veteran has a current disability of erectile dysfunction. Importantly, the Veteran asserts that the claimed erectile dysfunction is due to the service-connected PTSD and the medications prescribed for PTSD. There is no medical opinion of record addressing the etiology of the erectile dysfunction, if any. Based on the above, a VA examination is warranted to assist in determining the etiology of the claimed erectile dysfunction and sterility, if any. Accordingly, the issues of service connection for erectile dysfunction and sterility are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to assist in determining the nature and etiology of any current erectile dysfunction and/or sterility (a physician who is knowledgeable in urology is preferred but not required). Following a review of all relevant evidence from the claims file, an interview with the Veteran to obtain a complete medical history (to include any relevant in-service and post-service injuries/diseases of the genitourinary system), an examination, and any necessary testing, the examiner is asked to offer the following opinions: a) Does the Veteran have a current disability of erectile dysfunction? b) If the Veteran has a current disability of erectile dysfunction, is it as likely as not (a 50 percent or greater degree of probability) that erectile dysfunction began during service or is etiologically related to active service? c) Is it at least as likely as not (a 50 percent or greater degree of probability) that the Veteran's current erectile dysfunction was permanently worsened in severity ("aggravated") by the service-connected PTSD, to include as a result of psychiatric medication? d) Does the Veteran have a current disability of sterility? e) If the Veteran has a current disability of sterility, is it as likely as not (a 50 percent or greater degree of probability) that sterility began during service or was etiologically related to service, including in-service exposure to herbicides? If the Veteran does not have a diagnosed disability of erectile dysfunction and/or sterility, the examiner should so state. In rendering the opinions requested above, the examiner should assume that the Veteran 1) is service-connected for PTSD; 2) was exposed to herbicides during service; and 3) has low sperm count. The examiner should also consider and address the Veteran's treating physician (Dr. T.S.) opinion that the low sperm count is related to exposure to Agent Orange. The examiner is informed that "aggravation" is defined for legal purposes as a chronic worsening of the underlying condition (versus a temporary flare-up of symptoms) that is beyond its natural progression of the disease or disability. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the non-service-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the non-service-connected disease or injury. 38 C.F.R. § 3.310(b). As such, if the examiner determines that any of the Veteran's non-service connected conditions were aggravated by either of his two service-connected disabilities, the examiner should indicate, to the extent possible, approximate level of the disorder (i.e., a baseline) before the onset of the aggravation. The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. A rationale should be given for all opinions and conclusions rendered. The opinions should address the particulars of this Veteran's medical history and the relevant medical science as applicable to these claims. 2. After completion of the above and any additional development deemed necessary, the claims of service connection for erectile dysfunction and sterility should be readjudicated in light of all the evidence of record. If the determinations remain adverse to the Veteran, he and his representative should be furnished with a Supplemental Statement of the Case. An appropriate period of time should then be allowed for a response before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs