Citation Nr: 1510878 Decision Date: 03/16/15 Archive Date: 03/27/15 DOCKET NO. 13-04 951 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to a rating in excess of 20 percent for amputation of the left second and third toes, with internal fractures of the fourth and fifth toes, to include arthritis and plantar fasciitis. 2. Entitlement to service connection for a right hip disorder, to include thoracolumbar degenerative joint disease, with scoliosis, to include as secondary to the Veteran's service-connected amputation of the left second and third toes with internal fractures of the fourth and fifth toes, to include traumatic arthritis and plantar fasciitis. 3. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for bilateral hearing loss. REPRESENTATION Veteran is represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD C. Banister, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1980 to April 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeals from rating decisions dated March 2011 and August 2011 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The issue of whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for bilateral hearing loss is addressed in the remand portion of the decision below and is remanded to the RO. FINDINGS OF FACT 1. Manifestations of the Veteran's service-connected amputation of the left second and third toes include partial amputation of the left second toe at the distal interphalangeal joint and complete amputation of the left third toe at the metatarsophalangeal joint, with removal of the metatarsal head. 2. Manifestations of the Veteran's service connected residuals of a left foot injury, to include internal fractures of the fourth and fifth toes, arthritis, and plantar fasciitis, include antalgic gait; ankylosis of the left fourth toe at 40 degrees; constant pain, tenderness, and swelling in the left foot, which is not relieved by nonsteroidal anti-inflammatory medication or plastazote insoles; and increased pain during flare-ups, which is precipitated by prolonged walking, standing, cold weather, and using foot-operated machinery. 3. The evidence of record shows that the Veteran's thoracolumbar degenerative joint disease, with scoliosis, is due to his service-connected amputation of the left second and third toes, with internal fractures of the fourth and fifth toes, to include arthritis and plantar fasciitis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for amputation of the left second and third toes have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. § 4.59, 4.71a, Diagnostic Code 5172 (2014). 2. The criteria for a separate 20 percent rating, but no more, for residuals of a left foot injury, to include internal fractures of the fourth and fifth toes, arthritis, and plantar fasciitis have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2014). 3. The Veteran's thoracolumbar degenerative joint disease, with scoliosis, is due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 187 (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, 120 (2004). Prior to the initial adjudication of the Veteran's above-captioned claims, the RO's September 2010 letter to the Veteran contained the requisite notice. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187; Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, including the opportunity to present pertinent evidence. Thus, the Board finds that the content requirements of the notice VA is required to provide have been met. See Pelegrini, 18 Vet. App. at 120. The duty to assist has also been satisfied. The RO obtained the Veteran's available treatment records. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that additional evidence relevant to the Veteran's above-captioned claims is available and not part of the record. See Pelegrini, 18 Vet. App. at 116. The Veteran was provided VA examinations in December 2010 and April 2013. Both examiners reviewed the Veteran's claims file and treatment records. The examiners also administered thorough clinical evaluations, which provided findings pertinent to the rating criteria and allowed for fully informed evaluations of the disability at issue, and rendered opinions addressing all of the salient questions presented by the Veteran's service connection claim. As such, the Board finds that the Veteran has been provided adequate VA examinations for purposes of adjudicating his claims. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of these claims, the Board finds that any such failure is harmless. See Mayfield, 20 Vet. App. at 542-43; See also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing that an error is harmful or prejudicial normally falls upon the party attacking the agency's determination); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974)("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). I. Increased Rating for a Left Foot Disability Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2014). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2014). In a May 1984 rating decision, service connection was granted for amputation of the left second and third toes, with fractures to the fourth and fifth toes (hereinafter referred to the Veteran's service-connected left foot disability), to which a 10 percent disability rating was assigned, effective April 22, 1984. See 38 C.F.R. § 4.71a, Diagnostic Code 5284-5173 (2014). In July 2006, the Veteran submitted a claim of entitlement to service connection for degenerative arthritis of the left foot, secondary to his service-connected left foot disability, and a claim of entitlement to a rating in excess of 10 percent for his service-connected left foot disability. In a May 2007 rating decision, the RO recharacterized the Veteran's service-connected left foot disability "to include traumatic arthritis" and increased the Veteran's disability rating to 20 percent, effective July 13, 2006. In September 2010, the Veteran submitted a claim of entitlement to service connection for plantar fasciitis, secondary to his service-connected left foot disability, and a claim of entitlement to a rating in excess of 20 percent for his service-connected left foot disability. In a March 2011 rating decision, the RO again recharacterized the Veteran's service-connected left foot disability "to include traumatic arthritis and plantar fasciitis" and continued the 20 percent disability rating. Thereafter, the Veteran perfected an appeal. A July 2010 letter from the Veteran's private treating physician indicates that the Veteran complained of constant pain and swelling in the left foot, which was progressively getting worse. The Veteran's physician stated that the Veteran's pain did not improve with nonsteroidal anti-inflammatory medication or plastazote insoles. A physical examination revealed a partial amputation of the distal portion of the left second toe and a complete amputation of the left third toe. There was swelling at the dorsal aspect of the left mid tarsal region and slight inflammation of the dorsal forefoot and the plantar aspect of the forefoot. Discomfort was noted upon inversion and eversion. The dorsalis pedis and posterior tibial pulses on the left foot were palpable. The left fourth metatarsal head was very palpable, slightly tender, and appeared to be slightly plantarflexed. Muscle strength was good. The Veteran's physician opined that there could be slight plantar fasciitis due to swelling and tenderness around the medial band of the left plantar fascia. The Veteran's physician also indicated that the Veteran appeared to be having weight bearing discomfort, discomfort in the arch, and pain on the dorsal aspect of the left foot. A December 2010 VA examination report reflects that the Veteran sustained an in-service injury to his left foot when a ramp dropped on his foot. As a result, the Veteran's left second toe was amputated at the distal interphalangeal (DIP) joint, and his left third toe was amputated at the metatarsophalangeal (MP) joint. The Veteran reported pain in the left forefoot, which he characterized as 4 or 5 out of 10 in severity and during flare-ups, 8 or 9 out of 10 in severity. The Veteran indicated that flare-ups were precipitated by prolonged walking, standing, cold weather, and operating machinery with his feet. He stated that his symptoms improve slightly when resting. The Veteran stated that he worked as a heavy equipment operator and a truck driver. He indicated that his foot pain made it more difficult to operate heavy equipment and drive a truck, noting that the left foot is used for the clutch on a truck and for various controls on heavy equipment. A physical examination revealed amputation of the left second toe at the DIP joint and total amputation of the left third toe at the MP joint. The skin of the foot was pink with normal circulation. There was a fracture of the fourth and fifth toes by history. Musculature proximal to the amputation was normal. There was no limitation of motion or instability in the joints above the amputation site. Range of motion of the left second toe was 15 degrees flexion at the MP joint. Range of motion of the fourth toe was 40 degrees flexion, and the toe was ankylosed at 40 degrees. Range of motion of the fifth toe was 90 degrees flexion at the DIP joint, with full extension. There was no additional limitation of motion after three repetitions. The Veteran's gait was antalgic. The examiner noted that the Veteran did not require the use of any special shoes, braces, or canes. However, the Veteran stated that he occasionally used a cane. There was no evidence of callosities, breakdown, or unusual shoe-wear indicating abnormal weight bearing. There was no evidence of hammertoes, high arch, claw foot, flat foot, hallux valgus, or other deformity other than the amputations. Imaging studies showed traumatic arthritis of the forefoot. The diagnoses were traumatic arthritis of the left metatarsals, traumatic amputation of the left second and third toe with internal fracture of the fourth and fifth toe, and plantar fasciitis, which the examiner opined was a result of alteration and gait due to the Veteran's service-connected left foot injury. An April 2013 VA examination report indicates that the Veteran had a history of a crushing injury to the left foot. A physical examination revealed amputation of the left second toe at the DIP joint and amputation of the left third toe at the MP joint, with removal of the metatarsal head. The examiner indicated that the Veteran's toe amputations and plantar fasciitis altered the gait of the rest of the foot. There was no evidence of Morton's neuroma, metatarsalgia, hammer toes, hallux valgus, hallux rigidus, or claw foot. There was no malunion or nonunion of the tarsal or metatarsal bones. It was noted that the Veteran occasionally wore left foot prescription inserts. The examiner stated the residuals of the Veteran's left foot injury, included pain to the plantar surface, extending from the base of the toes to the heal area through the arch, as "moderately severe." There was no evidence of bilateral weak foot. The diagnoses were post-fracture of the fourth and fifth left toes, with degenerative joint disease and plantar fasciitis. The Veteran's service-connected left foot disability, to include traumatic arthritis and plantar fasciitis, has been assigned a disability rating pursuant to the criteria set forth in 38 C.F.R. § 4.71a, Diagnostic Code 5284-5173. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2014). In this case, the hyphenated diagnostic code indicates that a foot injury, under Diagnostic Code 5284, was the service-connected disability, and the amputation of toes, under Diagnostic Code 5284, was a residual condition. The May 2007 rating decision indicated that instead of assigning a separate disability rating for arthritis, the RO "included the evaluation with [the] current 10 percent for a 20 [percent] evaluation." Pursuant to Diagnostic Code 5173, a 10 percent disability rating is assigned for the amputation of three or four toes, without metatarsal involvement, not including the great toe. A maximum 20 percent disability rating is assigned for the amputation of three or four toes, without metatarsal involvement, including the great toe. 38 C.F.R. § 4.71a, Diagnostic Code 5173. The evidence of record indicates that the Veteran had two toes amputated, one with metatarsal involvement. Accordingly, the Board finds that the Veteran's toe amputations are more appropriately evaluated under Diagnostic Code 5172, relating to the amputation of one or two toes, other than the great toe. See 38 C.F.R. § 4.71a, Diagnostic Code 5172. Pursuant to Diagnostic Code 5172, a noncompensable rating is assigned for the amputation of toes, other than the great toe, without metatarsal involvement. A maximum 20 percent disability rating is assigned for amputation of one or two toes, other than the great toe, with removal of the metatarsal head. 38 C.F.R. § 4.71a, Diagnostic Code 5172. The evidence of record shows that the Veteran's left second toe was amputated at the DIP joint, and his left third toe was amputated at the MP joint, with removal of the metatarsal head. Thus, the Veteran's amputations alone meet the diagnostic criteria for a maximum 20 percent disability rating under Diagnostic Code 5172. See 38 C.F.R. § 4.71a, Diagnostic Code 5172. The Board has considered whether the Veteran's toe amputations warrant a higher disability rating under an alternative diagnostic code pertaining to amputation of toes. However, the medical evidence of record does not show amputation of all toes or amputation of the great toe. See 38 C.F.R. § 4.71a, Diagnostic Codes 5170, 5171 (2014). Therefore, a higher rating is not warranted for the amputation of toes under an alternative diagnostic code. The Veteran asserts that he is entitled to a separate disability rating based on the residuals of his foot injury, including arthritis and plantar fasciitis. Generally, evaluating of the same disability under various diagnoses, which is known as "pyramiding," is to be avoided. 38 C.F.R. § 4.14 (2014). However, where a veteran has multiple problems due to a service-connected disability, it is possible for the veteran to have separate and distinct manifestations from the same injury, permitting separate disability ratings. For purposes of determining whether a veteran is entitled to separate ratings for different problems or residuals of an injury, such that separate ratings do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). In this case, a 20 percent disability rating has been assigned based on the amputation of two toes, one with metatarsal involvement. The criteria set forth in Diagnostic Code 5172 do not contemplate any symptoms other than the removal of toes. See 38 C.F.R. § 4.71a, Diagnostic Code 5172. The evidence shows that the Veteran's residuals of his in-service left foot injury also include diagnoses of arthritis and plantar fasciitis, with symptoms of left foot pain, tenderness, swelling, antalgic gait, and ankylosis. As these symptoms are not contemplated by the criteria set forth in Diagnostic Code 5172, the Board finds that the Veteran may be entitled to a separate disability rating based the residuals of his in-service foot injury. Pursuant to Diagnostic Code 5284, a 10 percent disability rating is warranted for a "moderate" foot injury; a 20 percent disability rating is warranted for a "moderately severe" foot injury; a 30 percent disability rating is warranted for a "severe" foot injury; and a maximum 40 percent disability rating is warranted when there is actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284. Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (2014). The residuals of the Veteran's in-service left foot injury are manifested by an antalgic gait; ankylosis at 40 degrees on the left fourth toe; constant pain, tenderness, and swelling in the left foot, which is not relieved by nonsteroidal anti-inflammatory medication or plastazote insoles; and increased pain during flare-ups, which is precipitated by prolonged walking, standing, cold weather, and using foot-operated machinery. After a physical examination demonstrated objective evidence of pain to the plantar surface extending from the base of the toes to the heal area through the arch, the April 2013 VA examiner characterized the residuals of the Veteran's left foot injury as "moderately severe." Based on this, the Board finds that the evidence reflects a disability picture that more nearly approximates a moderately severe foot injury. See 38 C.F.R. § 4.7 (2014). As such, the Board finds that a separate disability rating of 20 percent is warranted pursuant to the criteria set forth in Diagnostic Code 5284. The evidence of record also indicates that the Veteran experienced constant foot pain, which he characterized as 4 or 5 out of 10 in severity and 8 or 9 out of 10 during flare-ups. The Veteran stated that his flare-ups were precipitated by prolonged walking, standing, cold weather, and operating machinery with his foot. While his left foot pain made it more difficult to perform occupational tasks, such as operating foot controls on heavy equipment and using the clutch while driving trucks, the Veteran has not indicated that his left foot disability prevented him from performing such tasks. He stated that his symptoms improved slightly after resting, and he was able to ambulate without assistance. According to a July 2010 letter from the Veteran's treating physician, strength in the left foot was normal. Based on this, the Board finds that the residuals of the Veteran's service-connected left foot disability are not "severe." See 38 C.F.R. § 4.71a, Diagnostic Code 5284. Thus, a 30 percent disability rating is not warranted under Diagnostic Code 5284. The Board has considered whether the residuals of the Veteran's in-service left foot injury warrant a higher disability rating under an alternative diagnostic code. However, the medical evidence of record does not show claw foot; severe malunion of the tarsal or metatarsal bones; or pronounced flatfoot with marked pronation, extreme tenderness of plantar surface, marked inward displacement, and severe spasm of the left tendo achillis on manipulation, which is not improved by orthopedic shoes or appliances. See 38 C.F.R. § 4.71a, Diagnostic Codes 5276, 5278, 5283 (2014). As such, a higher schedular rating is not warranted under an alternative diagnostic code. Generally, evaluating a disability using the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2014). Because the ratings are averages, an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2014). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical"). Therefore, initially, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds the Veteran's disability picture is not so unusual or exceptional in nature as to render the already assigned schedular ratings inadequate. The residuals of the Veteran's left foot injury, to include amputation of the left second and third toes with internal fractures of the fourth and fifth toes, arthritis, and plantar fasciitis, are evaluated as musculoskeletal disorders, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his left foot disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5172, 5284. Throughout the pendency of this appeal, the Veteran's service-connected left foot disability was manifested by partial amputation of the left second toe; complete amputation of the left third toe, with removal of the metatarsal head; antalgic gait; ankylosis at 40 degrees on the left fourth toe; constant pain, tenderness, and swelling in the left foot, which is not relieved by nonsteroidal anti-inflammatory medication or plastazote insoles; and increased pain during flare-ups, which is precipitated by prolonged walking, standing, cold weather, and using foot-operated machinery. The Rating Schedule provides for ratings in excess of those already assigned for certain manifestations of foot disabilities, but the Board finds that the evidence of record does not demonstrate that sufficient symptoms were present for any distinct period throughout the appeal period. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Additionally, the Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014). However, in this case, there are no additional symptoms that have not been attributed to a specific service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. In reaching this decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against assigning the Veteran's service-connected left foot disability ratings in excess of 20 percent for toe amputations and 20 percent for arthritis and plantar fasciitis, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). II. Service Connection for Thoracolumbar Degenerative Joint Disease with Scoliosis In September 2010, the Veteran filed a claim of entitlement to service connection for a right hip disability, to include as secondary to the Veteran's service-connected left foot disability. As will be discussed herein, the Veteran does not have a diagnosed right hip disability. However, the evidence of record indicates that after reporting symptoms of pain near the right hip, the Veteran received a diagnosis of thoracolumbar degenerative joint disease with scoliosis. Thus, interpreting the Veteran's claim broadly, the Board has recharacterized the Veteran's service connection claim as one for thoracolumbar degenerative joint disease, with scoliosis. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 U.S.C.A. § 1113(b) (West 2014); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). In order to establish direct service connection for a disability, there must be: (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet. App. 341, 346 (1999). Service connection may be established on a secondary basis for a disability, which 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). During an April 2013 VA examination, the Veteran reported pain and tenderness to the right lateral area above the right hip. The examiner noted that the painful area identified by the Veteran was actually the lower back, and not the hip. A physical examination revealed pain with palpation to the lower lumbar spine with spasms and moderate pain radiating to the area above the right hip. The examiner indicated that the Veteran's radiculopathy involved the sciatic nerve roots. Imaging studies of the thoracolumbar spine confirmed the presence of arthritis. The diagnosis was thoracolumbar degenerative joint disease with scoliosis. The examiner opined that it is "as least as likely as not that the problems of the lower back are secondary to the altered gait[,] which is secondary to the amputations of the toes of the left foot." In support of this opinion, the examiner provided the following rationale: [The Veteran] does have [a history of] amputation of the toes of the left foot. This amputation produces an abn[ormal] gait [which] produces unlevel horiz[ontal] level of the hips and altered vertical level of the lower back. In this, and in other cases, the Board may not base a decision on its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). A review of the record reveals that the only medical opinion addressing the etiology of the Veteran's thoracolumbar degenerative joint disease with scoliosis establishes a link between that diagnosis and the Veteran's service-connected left foot disability. Given that there is no evidence of record that disassociates the Veteran's thoracolumbar degenerative joint disease with scoliosis from his service-connected left foot disability, the Board finds that the evidence is at least in equipoise and, therefore, applying the benefit-of-the-doubt doctrine, service connection for thoracolumbar degenerative joint disease with scoliosis is warranted. Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A disability rating in excess of 20 percent for toe amputations is denied. A separate disability rating of 20 percent for residuals of a left foot injury, to include internal fractures of the fourth and fifth toes, arthritis, and plantar fasciitis, is granted, subject to the law and regulations governing the payment of monetary benefits. Service connection for thoracolumbar degenerative joint disease, with scoliosis, is granted. REMAND In April 2011, the Veteran submitted a claim to reopen the issue of entitlement to service connection for bilateral hearing loss, which was previously denied in a May 2007 rating decision. The Veteran contends that his current hearing loss was caused by in-service noise exposure while working as a heaving equipment operator. During an April 2013 VA audiological examination, the Veteran was provided a diagnosis of left ear sensorineural hearing loss in the frequency range of 500 to 4000 Hertz. The examination revealed normal hearing the right ear. The examiner opined that the Veteran's left ear hearing loss was not caused by or a result of the Veteran's service. In support of this opinion, the examiner provided the following rationale: Audiometric results available in the Veteran's case file revealed normal pure tone thresholds without significant threshold[] shifts at any frequencies on admission and two months prior to dismissal from military service. Stipulation would be in effect if the Veteran was exposed to extreme noise exposure between [February] 1984 and dismissal in April 1984. The Board finds that the April 2013 VA examiner's opinion is inadequate for two reasons. First, the opinion contains only data and conclusions without any supporting analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion that contains only data and conclusions without any supporting analysis is accorded no weight). Second, the examiner's opinion appears to be premised entirely on a finding that the Veteran's hearing was within normal limits during service and at separation. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993) (holding that even if hearing loss, as defined by 38 C.F.R. § 3.385, is not shown in service or at separation, medical evidence can establish service connection by showing that hearing loss is actually due to incidents during service). Thus, a remand is necessary to obtain a supplemental opinion that addresses whether the Veteran's current hearing loss was caused by in-service noise exposure. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, VA must provide an adequate one or, at a minimum, notify the veteran why one will not or cannot be provided). Accordingly, the case is remanded for the following action: 1. The Veteran's claims file and all electronic records must be made available to the April 2013 VA examiner for a supplemental opinion. If the April 2013 VA examiner is not available, the evidence of record must be provided to another appropriate examiner. The examiner must review all pertinent records associated with the claims file, and the examiner must specify in the examination report that these records have been reviewed. After reviewing the evidence of record, the examiner must provide an opinion as to whether any current hearing loss is related to the Veteran's service. In doing so, the examiner must specifically consider and discuss evidence other than just the Veteran's normal audiograms during service and at discharge. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 2. After the development requested has been completed, the RO must review the examination report to ensure that it is in complete compliance with the directives of this Remand. If the report is deficient in any manner, the RO must implement corrective procedures at once. 3. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim of entitlement to service connection for bilateral hearing loss must be re-adjudicated. If the benefit sought on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs