Citation Nr: 1529563 Decision Date: 07/10/15 Archive Date: 07/16/15 DOCKET NO. 13-00 187 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for elevated liver enzymes (also claimed as idiopathic liver disease) and, if so, whether service connection is warranted. 2. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a left ankle sprain (claimed as left ankle fracture) and, if so, whether service connection is warranted. 3. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for right knee pain (also claimed as bone spurs and patellar tendonitis) and, if so, whether service connection is warranted. 4. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for left knee pain (also claimed as bone spurs and patellar tendonitis) and, if so, whether service connection is warranted. 5. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for low back pain (claimed as lumbar spine condition and sciatica) and, if so, whether service connection is warranted. 6. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 7. Entitlement to a compensable rating for hypertension. 8. Entitlement to a compensable rating for bilateral hearing loss. 9. Entitlement to a compensable rating for pseudofolliculitis barbae with facial scars, prior to March 22, 2010, and in excess of 30 percent thereafter. ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran served on active duty from February 1985 to February 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decision issued in June 2010 (for PTSD) and April 2010 (for all other claims) by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In a November 2012 statement of the case, the RO also granted a 30 percent disability rating for pseudofolliculitis barbae (effective March 22, 2010). The Board notes that the Veteran has claimed entitlement to service connection for PTSD. Construing the claim liberally, however, the Board finds that it should be characterized as one for service connection for an acquired psychiatric disorder, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (per curiam order) (it is the responsibility of the Board to consider alternate current conditions within the scope of the claim). The issue is thus restated on the title page of this decision. As a final preliminary matter, the Board notes that the claims file reflects that the Veteran was originally represented by the North Carolina Department of Veterans Affairs, which was revoked in August 2011 (as reflected in a January 2011 VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative). In May 2011, the Veteran filed a VA Form 21-22a, Appointment of Individual as Claimant's Representative, appointing Jan Dils as his attorney. In a July 2013 letter, Jan Dils withdrew her representation of the Veteran. The Board now recognizes the Veteran as proceeding pro se. The issues of entitlement to an increased rating for hypertension and pseudofolliculitis barbae with facial scars, as well as, service connection for elevated liver enzymes, and an acquired psychiatric disorder are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In a final decision issued in August 2005, the RO determined that service connection for elevated liver enzymes (claimed as idiopathic liver disease), a left ankle sprain (claimed as left ankle fracture), bilateral knee pain (claimed as bone spurs and patellar tendinitis), and low back pain (claimed as lumbar spine condition and sciatica) was not warranted. 2. Evidence added to the record since the final August 2005 relates to unestablished facts necessary to substantiate the Veteran's claim of entitlement to service connection for elevated liver enzymes. 3. Evidence added to the record since the final August 2005 does not relate to unestablished facts necessary to substantiate the Veteran's claims of entitlement to service connection for a left ankle sprain, bilateral knee pain, and low back pain. 4. For the entire appeal period, the Veteran's bilateral hearing loss is manifested by Level II hearing for the right ear and Level I hearing for the left ear. CONCLUSIONS OF LAW 1. The August 2005 rating decision that denied service connection for elevated liver enzymes, a left ankle sprain, bilateral knee pain, and low back pain is final. 38 U.S.C.A. § 7105(c) (West 2014); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2014). 2. New and material evidence has been received to reopen the claims of entitlement to service connection for elevated liver enzymes. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2014). 3. New and material evidence has not been received to reopen the claims of entitlement to service connection for a left ankle sprain, bilateral knee pain, and low back pain. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2014). 4. For entire appeal period, the criteria for a compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.85, Diagnostic Code 6100 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). 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 regarding the disability rating and effective date for the award of benefits if service connection is awarded. Id. at 486. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. The U.S. Court of Appeals for the Federal Circuit previously held that any errors in notice required under the VCAA should be presumed to be prejudicial to the claimant unless VA shows that the error did not affect the essential fairness of the adjudication. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Under Sanders, VA bore the burden of proving that such an error did not cause harm. Id. In the case Shinseki v. Sanders, 129 S.Ct. 1696 (2009), however, the U.S. Supreme Court held that the Federal Circuit's blanket presumption of prejudicial error in all cases imposed an unreasonable evidentiary burden upon VA. Rather, in Shinseki v. Sanders, the Supreme Court suggested that determinations concerning prejudicial error and harmless error should be made on a case-by-case basis. Id. As such, in conformance with the precedents set forth above, on appellate review the Board must consider, on a case-by-case basis, whether any potential VCAA notice errors are prejudicial to the claimant. In Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court held that the VCAA notice requirements in regard to new and material evidence claims require VA to send a specific notice letter to the claimant that: (1) notifies him or her of the evidence and information necessary to reopen the claim (i.e., describes what is meant by new and material evidence); (2) identifies what specific evidence is required to substantiate the element or elements needed for service connection that were found insufficient in the prior denial on the merits; and (3) provides general VCAA notice for the underlying service connection claim. An October 2009 letter provided by the RO provided information consistent with those requirements. However, VA has since determined that such requirements are inconsistent with the subsequent Federal Circuit decisions in Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009) ("Vazquez-Flores II') and Wilson v. Mansfield, 506 F.3d 1055, 1059 (Fed. Cir. 2007). See VAOPGCREC 6-2014 (2014). As to the increased rating claims, in the instant service connection case, the Board finds that VA has satisfied its duty the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, the October 2009 letter also letter advised the Veteran of the evidence and information necessary to substantiate his increased rating claims, as well as his and VA's respective responsibilities in obtaining such evidence and information. The October 2009 letter further included notice of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and VA has complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). VA has a duty to assist the Veteran in developing his claim, which includes assisting the Veteran in obtaining any outstanding records of identified VA or private medical treatment relevant to his claim, and affording him an examination when appropriate. Relevant to the duty to assist, the AOJ obtained and considered the Veteran's service treatment records as well as post-service VA treatment records. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. Although the Board is remanding some claims for further development, to include obtaining more recent VA medical records, the Board finds that such records need not be obtained in reference to the current claims as the records associated with the claims file do not document current treatment for such disorders. Also, Veteran has not indicated that he has sought treatment for such disorders. Therefore, the Board finds that VA has met its duty to assist the Veteran in obtaining relevant records. The Board notes that the Veteran has not been provided with VA examinations in connection with his application to reopen his previously denied claims of entitlement to service connection for left ankle sprain, bilateral knee pain, and low back pain; the VCAA and its implementing regulations include clear guidelines consistent with the intent of Congress regarding the timing and the scope of assistance VA will provide to a claimant who attempts to reopen a previously denied claim. See 38 C.F.R. § 3.159(c)(1),(2) and (3). Such assistance includes obtaining service records, records in the custody of a Federal agency, and private records adequately identified by the claimant, but, prior to reopening a claim, there is no duty to obtain a VA medical examination or opinion. However, the Court has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Factors to consider in determining whether an examination is necessary include whether there is evidence of a current disability, and whether there is evidence that the disability may be associated with the appellant's military service or another service-connected disability but there is not sufficient medical evidence to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In the present case, the Veteran does not have currently diagnosed disorders of the left ankle, bilateral knees, or low back. Therefore, the Board finds that VA examinations and/or opinions are not necessary to decide these claims. In regards to the bilateral hearing loss increased rating claim, the Board finds that adequate information is associated with the claims file to rate the Veteran's claims. The Veteran underwent VA examination in March 2010 and VA medical records do not document any further complaints of, or treatment for, such disorder. Furthermore, the Veteran has not indicated that such disorders have worsened since his last VA examination. Neither the Veteran nor his representative (for the time period he had one) has alleged that either examination was inadequate for rating purposes. Moreover, the Board finds that the examination is adequate in order to evaluate the Veteran's disability, as it included interview with the Veteran, review of the record and full physical examination, addressing the relevant rating criteria. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-83 (2007); VAOPGCPREC 11-95 (1995). Therefore, the Board finds that the examination report of record is adequate to adjudicate the Veteran's rating claim and no further examination is necessary. The Veteran was also offered an opportunity to provide testimony at a Board hearing; however, in an August 2014 statement, he withdrew his request. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. New and Material Evidence Claims The Veteran contends that he has elevated liver enzymes, a left ankle sprain, bilateral knee pain, and low back pain that developed during service and have continued to the present. Service treatment records document occasional complaints of, or treatment for, the claimed disorders, including the left ankle (February 1986 and May 1999 sprains); knee complaints (October 1988 right knee strain and contusion, November 1999 chondromalgia patellae of the left knee, May 1991 right knee sprain, March 1992 bilateral knee pain complaint); low back pain (June 1999 following a motor vehicle accident, November 1996 muscle spasm); and occasional reports of elevated liver function tests (April 2001 and May 2005 records). His June 2004 report of medical history, prior to retirement, the Veteran reported knee trouble, swollen or painful, and back pain. The examiner found that the Veteran was generally normal. Following his February 2005 separation from service, an April 2005 VA examination diagnosed the Veteran with ankle fracture - there were X-rays of old fracture, bilateral knee pain with no objective findings, elevated liver enzymes, and low back pain, with no objective findings. In the August 2005 rating decision, the RO determined that the elevated liver enzymes (also claimed as idiopathic liver disease) were not considered an actually disabling condition subject to service connection. The RO also determined that service connection for left ankle sprain (claimed as left ankle fracture) was not warranted as the evidence does not show any chronic residual disability related to that condition. The RO further denied service connection for bilateral knee pain and low back pain as pain. The RO determined that pain in and of itself, was not considered an actually disabling condition subject to service connection. AOJ decisions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of an AOJ decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105(b) and (c); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.202, and 20.302(a). The appellant did not file an application for review on appeal within one year of the decision. Therefore, such decision is final. In this regard, the Board has considered the applicability of 38 C.F.R. § 3.156(b), which provides that when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim that was pending at the beginning of the appeal period. However, in the instant case, such regulation is inapplicable as; the AOJ has not received any new and material evidence regarding any claim within the year following the August 2005 decision. The AOJ received no evidence pertaining to this claim prior to the expiration of the appeal period. See also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). Thereafter, the RO received the appellant's petition to reopen the claim in October 2009. Generally, a claim that has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Since the October 2009 claim, the Veteran has a current diagnosis of a liver disorder, specifically a fatty liver. (October 2012 VA medical record). The additional evidence relates to unestablished fact necessary to substantiate the claim for service connection for elevated liver enzymes, and raises a reasonable possibility of substantiating the claim when considered with the old evidence. The claim for entitlement to service connection for elevated liver enzymes is reopened. As to the left ankle sprain, right left knee pain, and low back pain claims, since the October 2009 claim, the RO received medical records without any indication of complaints of, or treatment for, the left ankle, right or left knee, or the low back. At most there were reports of a medical history involving the left ankle (December 2010 VA medical record) and a report by the Veteran that he had left knee pain that inhibited his ability to work (March 2010 general VA examination). A November 2010 VA medical record documented no leg (including knee), foot or extremities limitations. The RO also received lay evidence from the Veteran repetitive of his previous reports of left ankle and low back injury in service. The Board concludes that the Veteran's statements regarding pain of the left ankle, bilateral knee, and low back are duplicative of the evidence of record at the time of the August 2005 rating decision and, therefore, is not new. On the other hand, the medical evidence received since the August 2005 rating decision is new, as it has not been previously considered. However, the evidence is not material because it does not show that the Veteran has a diagnosed disorder of the left ankle, right or left knee, or low back or that such disorders are related to service. Therefore, the additional evidence received, while new, is not material since it does not relate to an unestablished fact necessary to substantiate each respective service connection claim, and does not raise a reasonable possibility of substantiating any of those claims. Accordingly, the Board finds that the claim for service connection for a left ankle sprain, bilateral knee pain, and low back pain may not be reopened. III. Bilateral Hearing Loss Claim The Veteran's service-connected bilateral hearing loss is currently assigned a noncompensable rating under 38 C.F.R. § 4.85, Diagnostic Code 6100. The Veteran contends that he is entitled to compensable rating. A. Applicable Law Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. 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. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. However, the Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Ratings of hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second. To rate the degree of disability for service-connected hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from level I, for essentially normal acuity, through level XI, for profound deafness. 38 C.F.R. § 4.85(h), Table VI. In order to establish entitlement to a compensable rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average pure tone decibel loss are met. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. These results are then charted on Table VI, Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII, as set out in the Rating Schedule. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. B. Factual Background and Analysis In conjunction with the current claim, the Veteran underwent a VA examination in March 2010. Word recognition testing revealed speech recognition ability of 88 percent for the right ear and 94 percent for the left ear. The audiogram reveals that pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 AVERAGE RIGHT 40 40 45 75 50 LEFT 35 40 55 75 51.25 The examination did not demonstrate an exceptional pattern of hearing loss. 38 C.F.R. § 4.86. Additionally, the audiometry test showed results that would equate to Level II hearing in the right ear and Level I hearing in the left ear, using Table VI. 38 C.F.R. § 4.85. Applying the percentage ratings for hearing impairment found in Table VII, such hearing levels result in a noncompensable disability rating. 38 C.F.R. § 4.85. The Board further finds that the evidence of record reflects no certification of language difficulties, inconsistent speech audiometry scores, or pure tone threshold findings of 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz as to warrant consideration as an exceptional pattern of hearing impairment. 38 C.F.R. § 4.86(b). Therefore, the Board finds that, for the entire appeal period, the Veteran has no worse than Level II hearing in the right ear and Level I hearing in the left ear. As such, he is not entitled to a compensable rating for his bilateral hearing loss. To the extent that the Veteran contends that his hearing loss is more severe than currently evaluated, the Board observes that while competent to report symptoms such as difficulty hearing, he is not competent to report that his hearing acuity is of sufficient severity to warrant a 10 percent or greater evaluation under VA's tables for rating hearing loss disabilities because such an opinion requires medical expertise (training in evaluating hearing impairment), which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Despite the foregoing, the Board acknowledges the Veteran's reports of difficulty hearing. Even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a compensable rating are not met. See Lendenmann, supra (assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered). The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the service-connected bilateral hearing loss; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. C. Extra-Schedular Consideration Additionally, the Board has contemplated whether an issue should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has considered the level of severity and symptomatology of the Veteran's service-connected bilateral hearing loss with the established criteria found in the rating schedule. While the Veteran has described the functional impairment he experiences as a result of his bilateral hearing loss, to include difficulty hearing. The Veteran denied that such hearing difficulty affected his usual activities of daily living. The Board finds that the Veteran's bilateral hearing loss is fully addressed by the rating criteria under which such disability is rated. The decibel loss and speech discrimination ranges designated for each level of hearing impairment in Tables VI and VIA were chosen in relation to clinical findings of the impairment experienced by veterans with certain degrees and types of hearing disability. In support of this finding, the Board points to the regulatory history of 38 C.F.R. §§ 4.85 and 4.86. In this regard, the rating criteria for hearing loss were last revised, effective June 10, 1999. See 64 Fed. Reg. 25206 (May 11, 1999). In forming these revisions, VA sought the assistance of the Veteran's Health Administration (VHA) in developing criteria that contemplated situations in which a Veteran's hearing loss was of such a type that speech discrimination tests may not reflect the severity of communicative functioning these veterans experienced or that was otherwise an extreme handicap in the presence of any environmental noise, even with the use of hearing aids. VHA had found through clinical studies of veterans with hearing loss that when certain patterns of impairment are present, a speech discrimination test conducted in a quiet room with amplification of the sounds does not always reflect the extent of impairment experienced in the ordinary environment. The decibel threshold requirements for application of Table VIA were based on the findings and recommendations of VHA. The intended effect of the revision was to fairly and accurately assess the hearing disabilities of veterans as reflected in a real life industrial setting. 59 Fed. Reg. 17295 (April 12, 1994). Accordingly, the Board finds that functional impairment due to hearing loss that is compounded by background or environmental noise is a disability picture that is considered in the current schedular rating criteria. Consequently, the Board concludes that referral of an issue for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim, when such claim is expressly raised by the Veteran or reasonably raised by the record. The Veteran has not raised the issue in regard to the bilateral hearing loss claim. The March 2010 audio VA examiner did note some hearing difficulty affecting occupational activities. However, in his March 2010 hypertension VA examination, the Veteran reported that his limitation with working was related to a right ankle and knee. At that time the Veteran indicated that he was employed, and since that time he has not indicated that he is unemployable due to his bilateral hearing loss. Therefore, the Board finds that the issue of entitlement to a TDIU does not warrant consideration. ORDER As new and material evidence has been received to reopen a claim for service connection for elevated liver enzymes, the appeal, to this extent, is granted. New and material evidence has not been received, the claim to reopen the service connection claim for a left ankle sprain is denied. New and material evidence has not been received, the claim to reopen the service connection claim for right knee pain is denied. New and material evidence has not been received, the claim to reopen the service connection claim for left knee pain is denied. New and material evidence has not been received, the claim to reopen the service connection claim for a low back pain is denied. A compensable disability rating for bilateral hearing loss is denied. REMAND The Veteran contends that he has a current liver disorder that developed in service, as evidenced by in-service elevated liver enzymes. He further contends that he developed an acquired psychiatric disorder, to include PTSD, due to service. He claims that he served in combat and with the Special Forces - in Somalia, Iraq, and Afghanistan. (July 2010 Vet Center record, October 2009 VA medical record). The Veteran additionally claims that a compensable disability rating is warranted for hypertension and a disability rating in excess of 30 percent is warranted for pseudofolliculitis barbae with facial scars. As to the claim related to elevated liver enzymes, the Veteran's service treatment records documented occasional elevated liver function tests and his original April 2005 VA examination noted elevated liver enzymes. Since that time, the Veteran has received a current diagnosis of a fatty liver. (October 2012 VA medical record). A VA examination is necessary to determine whether the Veteran's current liver disorder is etiologically related to service. 38 C.F.R. § 3.156; see McLendon v. Nicholson, 20 Vet. App. 79 (2006). As to the Veteran's acquired psychiatric disorder claim, the Veteran claims that he has PTSD due to service. Service connection for PTSD requires a medical diagnosis of the disorder; credible supporting evidence that the claimed in-service stressful events actually occurred; and a link, as established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f). The Board notes that the regulation for PTSD has been updated, effective July 12, 2010, relaxing stressor verification requirements for stressors related to a veteran's fear of hostile military activity. 38 C.F.R. § 3.304 (f), 75 Fed. Reg. 39,843 (Jul 13, 2010). The AOJ should provide the Veteran with updated notice regarding PTSD stressor verification. The AOJ should also provide the Veteran another opportunity to provide information regarding his claimed stressors. Also, in a June 2010 VA Memorandum, the RO determined that the Veteran had not provided requested stressor information and that insufficient evidence was of record to obtain stressor corroboration. The Board notes, however, that the Veteran has claimed to be with the Special Forces and to have served in combat - in Somalia, Iraq, and Afghanistan. (October 2009 and November 2010 VA medical records). The Veteran's DD 214 documents that for two and a half years prior to his discharge he served as a barber. A March 2000 service treatment record documents that the Veteran was evaluated as to his qualifications for working in the ship's laundry. However, given the Veteran's contentions, the AOJ should determine whether the Veteran did indeed serve with the Special Forces and/or in combat. Additionally, the Veteran has diagnoses of PTSD; depression, not otherwise specified; and adjustment disorder, with mixed moods. (November 4 and 8, 2010 VA medical records). A VA examination is necessary to determine whether he has a psychiatric disorder etiologically related to service. 38 C.F.R. § 3.156; see McLendon, supra. In regards to the hypertension claim, the Veteran underwent a VA examination in March 2010. At that time, the Veteran did not take medication to control his hypertension. Since that time, the Veteran's hypertension appears to have worsened; the Veteran is currently using medication to control his hypertension. (November 2010 and May 2012 VA medical records). To ensure that the record includes sufficient medical evidence to properly evaluate the disability under consideration, the Board finds that a more contemporaneous examination, with findings responsive to the applicable rating criteria, is needed. See 38 C.F.R. § 5103A; 38 C.F.R. § 3.159; Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). As to the pseudofolliculitis barbae with facial scars claim, the Veteran underwent a March 2010 VA examination. Unfortunately, a new VA examination is necessary as the examiner did not address all necessary rating information, including whether the Veteran had visible or palpable tissue loss or surface contour of scar elevated or depressed on palpation. 38 C.F.R. § 4.2 (when an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes). The Board also notes that the Veteran receives VA treatment, to include through the Salisbury VA Medical Center and the Vet Center. Therefore, while on remand, VA treatment records from the Salisbury VA medical center (from October 2012 to the present) and Vet Center (from October 2010 to the present) should also be obtained for consideration in the appeal. Accordingly, the case is REMANDED for the following actions: 1. (a) The AOJ should provide the Veteran notice consistent with the VCAA, to include the relaxed stressor verification requirements for stressors related to a veteran's fear of hostile military activity. 38 C.F.R. § 3.304 (f), 75 Fed. Reg. 39,843 (Jul 13, 2010). (b) The AOJ should provide the Veteran another opportunity to provide information regarding his claimed stressors. 2. The AOJ should obtain all unassociated VA treatment records, to include from the Salisbury VA medical center (from October 2012 to the present) and the Vet Center (from October 2010 to the present). All reasonable attempts should be made to obtain such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. The AOJ should undertake appropriate efforts to (a) verify the Veteran's allegation that he was with the Special Forces and served in combat and (b) and other stressors he may identify. 4. After the above development has been accomplished, schedule the Veteran for a VA psychiatric examination before an appropriate specialist. The Veteran's claims file and copy of this remand must be provided to the examiner for review. All indicated tests and studies, including psychological testing, should be accomplished, and all clinical findings should be reported in detail and correlated to a specific diagnosis(es). The examiner should address the following: (a) Does the Veteran meet the criteria for a diagnosis of PTSD? If the answer is "Yes, is it at least as likely as not (probability of at least 50 percent), that there is a causal connection between any current symptoms of PTSD and any verified stressor (if found)? (b) If PTSD is diagnosed, is it at least as likely as not (probability of at least 50) that such diagnosis is related to a fear of hostile military or terrorist activity? The Board notes that "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. (c) If PTSD is diagnosed, please specifically identify the particular stressor(s) upon which the diagnosis is predicated. (d) Does the Veteran meet the criteria for any psychiatric disorder OTHER THAN PTSD? If the answer is "Yes," please provide the diagnosis for each such mental disorder found to exist. (e) For each diagnosis of an acquired psychiatric disorder OTHER THAN PTSD, is it at least as likely as not (probability of at least 50 percent) that any such mental disorder developed during, was caused by, or is it the result of, any event that occurred during service? (f) If the examiner finds that the Veteran DOES NOT meet the criteria for any diagnosis of an acquired psychiatric disorder, to include PTSD, he/she should explain the medical basis for that finding, and should reconcile his/her opinion with any conflicting findings and opinions of record. The basis for each opinion is to be fully explained with a complete discussion of the pertinent lay and medical evidence of record and sound medical principles, including the use of any medical literature (if deemed warranted) or studies, which may reasonably explain the medical guidance in the study of this case. The Board notes that the narrative portion of the REMAND contains some background history regarding the Veteran's claim; however, it is the examiner's responsibility to review all applicable evidence of record. The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, the examiner must provide an explanation for such rejection. 5. After all outstanding records have been associated with the claims file, the Veteran should be afforded an appropriate VA examination to determine the current nature and etiology of any liver disorder. Based on examination findings, including any necessary diagnostic studies, as well as a review of the claims file, including treatment records, the Veteran's statements, and a copy of this REMAND, the examiner is requested to render opinions as to the following: a) Does the Veteran currently have a liver disorder? If so, please specify any current diagnosis. b) Is it at least as likely as not that any liver disorder(s) is related to the Veteran's active service? The examiner should specifically consider (i) the Veteran's in-service elevated liver function test findings during service (including in March 2000, May 2000, April 2001, September 2002 service treatment records) and (ii) the Veteran's reports of alcohol use in service and after service and opine as to whether such use caused the Veteran's current liver disorder (January 2000 service treatment record, December 2010 VA medical record). In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the incurrence and continuity of symptomatology and the results of his prior VA examinations. An explanation for any opinion offered should be provided. 6. After all requested records have been obtained, schedule the Veteran for a hypertension examination to determine the current severity of his hypertension. The examiner must review the claims folder in conjunction with the examination. All indicated tests should be performed and the results reported. The examiner should describe all symptomatology related to the Veteran's service-connected hypertension. The examiner should determine the Veteran's predominant diastolic pressure and systolic pressure reading levels over the claim period (from October 2009 to the present). A rationale for any opinion expressed should be provided. 7. After obtaining all outstanding records, the AOJ should schedule a new skin VA examination to determine the current severity and all manifestations of his service-connected pseudofolliculitis barbae, with facial scars. The Veteran's claims folder must be made available to the examiner for review in conjunction with the examination. The examiner should indicate in examination report if the claims file was reviewed. In assessing the scar(s) on examination, the examiner should describe the nature and severity of all manifestations of the pseudofolliculitis barbae with facial scars, to include addressing the following inquiries: Specifically identify the areas of the body affected, as well as the percentage of the entire body, and the percentage of the exposed areas affected. The examiner should also clearly indicate whether the disability requires the use of systemic therapy such as corticosteroids or other immunosuppressive drugs, and, if so, the frequency of such use during the prior 12-month period. The examiner should also note whether there is visible or palpable tissue loss; gross distortion or asymmetry of features (and if so which ones); and whether (and if so which) characteristics of disfigurement are present. The examiner should further note characteristics of scars, to include whether they are unstable, painful, superficial, or cause additional loss of motion or function. In addition to objective findings, the examiner should fully describe the Veteran's lay accounts of functional effects caused by the scar/scarring in the final report of the evaluation, such as those impacting daily activities and ability to perform functions related to employment. All opinions must be supported by a clear explanation, if necessary with citation to relevant medical findings, as appropriate. 8. When the development requested has been completed, the case should again be reviewed by the AOJ on the basis of the additional evidence. If a benefit sought is not granted, the AOJ should furnish the Veteran a supplemental statement of the case and a reasonable opportunity to respond before returning the record to the Board for further review. 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 2014). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs