Citation Nr: 1547044 Decision Date: 11/06/15 Archive Date: 11/13/15 DOCKET NO. 13-08 756 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for residuals of a forehead laceration. 2. Entitlement to service connection for a back disability. 3. Entitlement to service connection for a headache disability. 4. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 5. Entitlement to service connection for a neck disability. 6. Entitlement to service connection for peripheral neuropathy of the upper extremities. 7. Entitlement to service connection for peripheral neuropathy of the lower extremities. 8. Entitlement to an initial compensable evaluation for bilateral hearing loss. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD N. Kroes, Senior Counsel INTRODUCTION The Veteran served on active duty from January 1966 to December 1967 and from July 1968 to November 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from May 2009 and July 2011 rating decisions of the Atlanta, Georgia, Department of Veterans Affairs (VA) Regional Office (RO). In June 2015, the Veteran testified during a video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The record was held open for 60 days after the hearing to allow for submission of additional evidence. The Veteran subsequently submitted an additional statement in support of claim. Service connection is currently in effect for a residual tender scar. The service-connected scar is in a semilunar pattern from mid cheek down the mandible under the chin and across to the other cheek. The Veteran's current claim for service connection is related to a different scar on his forehead. Given the Veteran's complaints of mental health problems and evidence of diagnoses of mental disorders other than PTSD, the Board has expanded his claim for service connection for PTSD to a claim for service connection for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the Board erred in not considering the scope of the Veteran's claim for service connection for posttraumatic stress disorder as including any mental disability that may reasonably be encompassed by the record.) The Board notes that the back and headache claims were previously denied by the RO in October 1987. However, as the file does not appear to contain notification to the Veteran of this decision or his appellate rights at the time the Board will consider the claims on the merits rather than first analyzing whether new and material evidence has been received in connection with the claims. See 38 U.S.C.A. 5108 (West 2014); 38 C.F.R. § 3.156 (2015). As the RO addressed each claim on the merits the Veteran is not prejudiced by the Board addressing the issues on the merits. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Veteran's claims folders are now encompassed completely in Virtual VA and Veterans Benefits Management System (VBMS) electronic files. The issues of entitlement to service connection for a neck disability, an acquired psychiatric disorder, and peripheral neuropathy of the upper and lower extremities 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 involved in a motor vehicle accident during service. 2. The Veteran has a scar on his forehead as a result of the in-service motor vehicle accident. 3. The Veteran's current back disability is unrelated to the in-service motor vehicle accident or any incident during service. 4. The Veteran's headaches are unrelated to the in-service motor vehicle accident or any incident during service. 5. The Veteran's bilateral hearing loss is manifested by no more than level V hearing in the right ear and level I hearing in the left ear. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for residuals of a forehead laceration (diagnosed as right mid forehead scar) have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015). 2. The criteria for establishing service connection for a back disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 3. The criteria for establishing service connection for a headache disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 4. The criteria for an initial compensable rating for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. § 3.159 (2015). The VCAA applies to the instant claims. In this decision, the Board grants service connection for a scar on the right mid forehead, which constitutes a complete grant of the benefit sought on appeal. As such, no discussion of VA's duties to notify or assist is necessary regarding that issue. The Veteran is challenging the initial evaluation assigned following the grant of service connection for bilateral hearing loss. The United States Court of Appeals for Veterans Claims (Court) has held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). Thus, because the notice that was provided before service connection was granted was sufficient, VA's duty to notify in this case has been satisfied as to that issue. Regarding the other issues decided in this decision, the duty to notify was satisfied in this case by January 2009, March 2010, and March 2011 letters. The claims were last readjudicated in February 2013. VA has also fulfilled its duty to assist. VA obtained the Veteran's service treatment records, service personnel records, and identified post-service treatment records. During the appeal period, VA provided the Veteran with relevant examinations. The examiners reviewed the Veteran's claims file, considered the Veteran's reported history, examined the Veteran, described his disabilities in detail, and provided analysis to support any conclusions reached. Therefore, the examinations are adequate and allow the Board to make an informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). The record reflects that at the June 2015 hearing the undersigned explained the issues, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. During the Veteran's hearing he testified that after being thrown out of a two and a half ton truck in August or September of 1967 he was medically evacuated by helicopter to a military hospital in Nuremburg, Germany for neck and back injuries. Board Hearing Tr. at 21-22. The Veteran indicated that this was a separate incident from the motor vehicle accident discussed throughout this decision, which occurred in 1969. Personnel records indicate that the Veteran served in Germany from May 29, 1966 to December 4, 1967. While the incident described by the Veteran is not reflected in the service treatment records, the Board finds that additional efforts to obtain hospital or other records related to the alleged incident need not be undertaken. The Board would expect that had this incident occurred there would be some reference to it in the service treatment records. For example, during his November 1969 separation examination the Veteran reported that he was in a separate motor vehicle accident but made no mention of any medical evacuation via helicopter in Germany. It is noted that the service treatment records do include a February 1967 report of pain in the right scapular area due to a fall and a November 1968 report of back pain after lifting heavy equipment. The later report makes no reference to any previous neck or back injury of the severity that medical evacuation via helicopter was necessary. In fact, the corresponding (negative) X-ray report indicates that the Veteran injured his back 3 days prior to the November 1968 X-ray. More importantly, in connection with his November 1969 separation examination the Veteran specifically denied having had back trouble of any kind. Given the Veteran's statements contemporaneous to service, the Board finds that further efforts to obtain records of the alleged incident in 1967 need not be undertaken. Given the above, no further action related to the duties to notify and assist is required in this case. Analysis I. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA has established certain rules and presumptions for chronic diseases. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Arthritis and organic diseases of the nervous system are considered by VA to be chronic diseases. 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013) Forehead laceration The Veteran alleges that he has a scar on his forehead as a result of an in-service motor vehicle accident. When the Veteran was examined at entry into service in November 1965 it was noted that he had abnormal identifying body marks, scars, or tattoos. Specifically, the examination report noted "S 21/2 (L) ARM". The Board interprets this as identifying a scar on the left arm. When the Veteran was examined at entry into his second period of service in July 1968 it was noted that he had a cut on his elbow. There is no mention of any forehead scar preexisting service. In March 1969 the Veteran was involved in a motor vehicle accident. The emergency room report of that incident indicates that he sustained a head laceration. On examination in connection with the Veteran's separation from service in November 1969 it was noted that he had a 1 1/2 inch horizontal scar on the right forehead which was well healed with no sequela. The Veteran underwent VA examination in November 2012 at which time the examiner noted the presence of a barely visible scar in line with the natural crease of the right mid forehead, well healed. While the examiner indicated that service records reflected a cut to the forehead due to a motor vehicle accident, no opinion about the etiology of the current forehead scar was offered. The Board finds that service connection is warranted for a right mid forehead scar. The Veteran did not have a forehead scar prior to service, lacerated his forehead during a motor vehicle accident during service, and currently has a scar on the forehead which he attests is related to the in-service forehead laceration. Given the above, it is clear that the forehead scar has been present since service and is related to the in-service motor vehicle accident. Back disability The Veteran alleges that he has a current back disability as a result of an in-service motor vehicle accident or otherwise related to his service. Service treatment records include a July 1967 separation examination report which indicates the Veteran had a normal spine at that time. He denied having any painful joints. When the Veteran reentered service in July 1968 spine and musculoskeletal examination was again normal. However, in November 1968 the Veteran did complain of back pain, noting that he strained his back lifting heavy equipment. Physical examination and X-ray of the thoracolumbar spine were negative. The Veteran was involved in a motor vehicle accident in March 1969. The corresponding emergency room report notes complaints of pain in multiple areas (tibia, ankle, foot, elbow) but makes no mention of any back pain. In June 1969 the Veteran reported experiencing dizziness, headache and back pain since his motor vehicle accident. However, later that month spine and musculoskeletal examination was normal. While the Veteran reported painful joints in connection with the June 1969 examination, the examiner's summary clarified that the report was related to the right knee. At separation in November 1969, spine and musculoskeletal examination was normal. While the Veteran complained of painful joints it was again noted that the Veteran was referencing right knee pain. The Veteran specifically denied having had back trouble of any kind. The Veteran was afforded a VA orthopedic examination in August 1987. At that examination he reported that his back started hurting in 1973 after he was out of service. He was injured lifting concrete and other materials and was hospitalized. He reported that since that incident he had experienced occasional low back pain which he treated with over the counter medication and a heating pad. After examining the Veteran, the examiner diagnosed chronic low back strain and opined that this was not service-connected as it occurred after the Veteran left service. The Veteran was afforded another VA examination of his back in November 2012. At that examination he reported that he experienced low back pain since a motor vehicle accident during service. After examining the Veteran, the examiner diagnosed lumbar strain with left lower extremity neuropathy and degenerative joint disease of the lumbar spine. Regarding whether the back disability was due to the car accident in service, the examiner stated that he could not resolve this issue without resorting to mere speculation as there was no objective evidence to support chronicity of the condition or of aggravation over and above its expected normal progression with aging and degenerative joint disease. The Board recognizes that before relying on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the review of the evidence. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). In this case, further development in the form of records development or supplemental medical opinion is not necessary. In 1987 the Veteran stated his back pain started in 1973 and he treated it with over the counter medication and a heating pad. Thus, there do not appear to be any additional treatment records to obtain to aid the examiner. In addition, the evidence of record - specifically the 1987 VA examination report and service treatment records - is sufficient to address the issue of etiology. The Board finds the service treatment records and the August 1987 VA examination report to be the most probative evidence of record. At separation from service the Veteran denied having had any back trouble and spine and musculoskeletal examination was normal. When the Veteran was examined by VA almost 18 years later he reported that his back problems began years after service due to an accident in 1973. Based on the above, the examiner opined that the Veteran did not have a service-connected back disability. This opinion, while offered years ago, is still probative today. The evidentiary picture has not changed significantly. The Veteran has a low back disability but the evidence reflects he did not have a back disability at separation or for years after service. Thus, the Board finds the opinion offered in 1987 to be adequate for addressing this issue. As the most probative evidence in this case is against a finding that the Veteran has a back disability that began during or is otherwise related to service, or arthritis manifest to a compensable degree during the year after service, service connection must be denied. The Board has considered the Veteran's statements in this case. While the Veteran is competent to report things that he observes, such as back pain, the Board finds his complaints of experiencing back pain since the motor vehicle accident in service to be lacking credibility. See 38 C.F.R. § 3.159(a); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that a Veteran is competent to report on that of which he or she has personal knowledge); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (Board can consider bias in lay evidence and conflicting statements of the veteran in weighing credibility). At separation from service the Veteran specifically denied having had back trouble of any kind. Then, during an October 1987 examination, he reported that his low back pain started after a post service accident in 1973. The Board finds the statements made by the Veteran contemporaneous with service and closer in time to service to be more credible than his current assertions. During his hearing, the Veteran testified that he had told VA he hurt his back while lifting and stated that his back had been hurting on and off since then. Board Hearing Tr. at 5. The current testimony also appears to be at odds with his statements that he has experienced low back pain since service. Given the above, the Board finds that the Veteran's credible statements indicate that his back pain began years after his separation from service, which tends to weigh against his claim for service connection and to support the conclusion of the VA examiner in 1987 - that the back disability is unrelated to service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that a lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim). The Board is also aware that a VA outpatient treatment record from one of the Veteran's physicians includes an assessment of "[l]ower back pain, chronic, ever since accident 1969." See November 4, 2010 Physician Note. It appears that the reference to onset in 1969 is a reflection of the Veteran's reported history to the physician rather than the physician's medical opinion regarding etiology or onset. Even if the assessment does reflect the physician's medical opinion, the opinion is afforded no probative weight as there is no rationale for the conclusion reached. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300-01 (2008) (holding that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). To the extent there is an implied rationale that there is a relationship to service based on the Veteran's report of pain since service, the Board still finds the (possible) opinion is of no probative weight as the Board has found the Veteran's report of back pain since service to be lacking credibility, which means that the physician was working with an inaccurate factual premise. The Board also recognizes that in his February 2013 substantive appeal the Veteran indicated that the most recent VA examiner stated that he needed to get magnetic resonance imaging (MRI), which the Veteran believed would support his claim. The need for further diagnostic study is not reflected in the examination report. Instead, the examiner stated that diagnostic testing is not clinically indicated at this time. It is noted that an MRI was obtained in 2013; however, the Board finds that an additional or supplemental medical opinion taking into account the findings of the MRI is not necessary. This claim is being denied as the Veteran's own statements, as well as the medical evidence, place the onset of his low back problems years after his separation from service. In short, further development is unnecessary to resolve this issue and has not been indicated by any medical professional. Given the above, the Board finds that the lay and medical evidence in this case is against a finding that the Veteran has a current back disability that is related to his military service, to include the in-service motor vehicle accident. Thus, service connection must be denied. Headaches The Veteran alleges that he has a current headache disability as a result of an in-service motor vehicle accident or otherwise related to his service. After the Veteran's motor vehicle accident during service, he reported having headaches on multiple occasions. For example, in June 1969 he reported having headaches since the accident, and at separation in November 1969 he reported experiencing headaches due to the accident. Of note, neurological evaluation at separation was normal. The Veteran was afforded a VA neuropsychiatric evaluation in August 1987. At that time he reported that he was in a car wreck during service. When asked if he had any present conditions he attributed to the accident the Veteran noted a sharp pain from time to time in the back of his head. A physical examination was performed and the examiner diagnosed depressive reaction and opined that residuals of a head injury were not found. During a November 2012 VA traumatic brain injury (TBI) and headache examination (two examination reports completed by the same physician), the Veteran reported that he had bad headaches since bashing his head into a windshield during an in-service motor vehicle accident. A physical examination was performed. The examiner opined that based on review of the medical records, medical literature and his clinical experience, the Veteran appeared to have a post-concussion syndrome after the accident in March 1969 with residual headaches and dizziness. However, the examiner further opined that there is no evidence this condition persisted after discharge from service, which the examiner explained was the typical course; that is, resolution of symptoms within 1 year. According to the examiner, the symptoms appeared to have resolved since the Veteran sought no evaluation or treatment of the issues for the next 18 years and when he did finally undergo a VA neuropsychiatric examination in 1987 there was no evidence of a chronic headache disorder. According to the examiner, the sharp pain in the back of the head reported at the 1987 examination does not imply a persistent post traumatic headache condition and is completely different than the headaches the Veteran describes today. The examiner opined that there is no evidence of residuals of concussion, including headaches. The examiner diagnosed chronic daily tension type headaches. At his hearing, the Veteran stated that his head hurts in the back and down the neck contrary to his previous report to the VA examiner. Board Hearing Tr. at 12. The implication being that the examiner's opinion is flawed. To explain his change in complaints the Veteran stated that he "should have told the truth" and that instead he "told a lie." Board Hearing Tr. at 12. Ultimately, the Veteran has made conflicting statements about his headaches which calls into question his credibility. The Veteran's assertion that he lied to a VA examiner further diminishes his credibility. As such, the Board is affording no probative weight to the Veteran's more recent statements regarding the history of his headaches. The Board finds that the most probative evidence in this case is the negative opinion offered by the VA examiner in November 2012. The examiner offered the opinion after examination of the Veteran and with knowledge of the pertinent medical history, including the in-service motor vehicle accident and headaches, and reports of headaches after service. The examiner recognized the complaints and explained that the Veteran had tension type headaches rather than residuals from the in-service concussion. The Board finds this opinion well-reasoned and highly probative. Given the above, the Board finds that the Veteran's current headache disability did not have its onset during service and is not otherwise related to service, to include the in-service motor vehicle accident, and that an organic disease of the nervous system did not manifest to a compensable degree within one year after separation from service. Thus, service connection for a headache disability must be denied. II. Initial Rating Bilateral hearing loss Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2015); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2015); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2015); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2015). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). As some disabilities may fluctuate in severity, the possibility that different ratings may be warranted for different time periods based on the facts found - a practice known as "staged" ratings - has been considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Francisco v. Brown, 7 Vet. App. 55 (1994). Evaluations of bilateral defective hearing range from non-compensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). To evaluate the degree of disability from bilateral service-connected defective hearing, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. §§ 4.85, Tables VI and VII, Diagnostic Code 6100. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. 38 C.F.R. § 4.86(a). Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be considered separately. 38 C.F.R. § 4.86(b). The Veteran was afforded a VA audiological examination in March 2011. He complained of bilateral hearing loss, and reported that he has difficulty hearing speech unless facing the talker and that some sounds bother him. On testing, pure tones were as follows. HERTZ 1000 2000 3000 4000 Average RIGHT 5 30 80 80 48.75 LEFT 10 15 60 50 33.75 An exceptional pattern of hearing impairment is not shown and 38 C.F.R. § 4.86 is not applicable. Speech recognition scores were 94 percent in the right ear and 96 percent in the left ear. Applying the findings of this examination, the Veteran is assigned Level I hearing for each ear. See 38 C.F.R. § 4.85, Table VI. Level I hearing in each ear corresponds to a noncompensable rating. See 38 C.F.R. § 4.85, Table VII. The Veteran was afforded another VA audiological examination in December 2011. He reported that he has to look at people when they are talking, that if there is any kind of background noise he cannot hear, and that amplified sound from public address systems bothers him. On testing, pure tones were as follows. HERTZ 1000 2000 3000 4000 Average RIGHT 15 35 85 85 55 LEFT 20 20 55 60 39 An exceptional pattern of hearing impairment is not shown and 38 C.F.R. § 4.86 is not applicable. Speech recognition scores were 72 percent in the right ear and 96 percent in the left ear. Applying the findings of this examination, the Veteran is assigned Level V hearing for the right ear and Level I hearing for the left ear. See 38 C.F.R. § 4.85, Table VI. Level V hearing and Level I hearing corresponds to a noncompensable rating. See 38 C.F.R. § 4.85, Table VII. The Board notes that schedular disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). In this case, the audiometric testing reveals findings that warrant a noncompensable rating. A higher rating on a schedular basis must therefore be denied. The Board has considered whether referral for an extraschedular rating is warranted. Extraschedular consideration requires a three-step inquiry. See 38 C.F.R. § 3.321(b)(1); see also Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the claimant's disability picture. Thun, 22 Vet. App. at 115. 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. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the claimant's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of Compensation to determine whether an extraschedular rating is warranted. The Board is of the opinion that the rating schedule measures and contemplates each aspect of the Veteran's hearing loss disability. As explained in the proposed rule for the current version of Diagnostic Code 6100, the criteria of Diagnostic Code 6100 were revised in 1987 with the goal of recognizing the impact of hearing loss in higher frequencies, and to provide a more accurate picture of true hearing impairment. See 52 Fed. Reg. 17607 (May 11, 1987). As a result, VA changed its testing methods and, in conjunction with the Department of Medicine and Surgery, developed amendments to 38 C.F.R. §§ 4.85, 4.86a, 4.87a and Tables VI and VII. In particular, pure tone averaging was to be accomplished using tone bursts at 1000, 2000, 3000 and 4000 Hertz, and speech recognition was to be measured using the Maryland CNC word lists which contained words with sounds in the 3000 and 4000 Hertz range. Overall, the new schedule was intended to evaluate hearing loss based on a combination of pure tone averages and speech discrimination, which was thought to provide for a more accurate representation of actual hearing impairment by recognizing that individuals with slight to moderate decibel loss as determined by pure tone averaging may have significant impairment of speech and vice versa. Additionally, the rating schedule was revised to accommodate language difficulties and other factors which produced inconsistent speech audiometry scores and to recognize exceptional patterns of hearing impairment. Notably, VA determined that "Table VII was developed during months of consultations with our Department of Medicine and represents the best judgment of experts in this field." Based upon the stated factors and considerations undertaken by VA and medical experts in developing the current criteria of Diagnostic Code 6100, the Board finds that the schedular rating currently assigned reasonably describes the Veteran's disability level and symptomatology. The Veteran's description of difficulty hearing has been measured according to pure tone averages and speech discrimination. The Board recognizes that the Veteran stated that he has to look at people when they are talking, that if there is any kind of background noise he cannot hear, and that some sounds, such as amplified sound from public address systems, bother him. However, as explained above, the rating criteria are designed to take into account testing that accurately measures difficulty hearing in an objective way and the Veteran's reports simply do not represent an exceptional case. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a 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. Service connection is currently in effect for residual tender scar, residuals of fracture of right mandible, tinnitus, and by way of this decision, a forehead scar. The Veteran's combined disability rating is 30 percent (not counting the rating to be assigned for the forehead scar as a result of this decision). Whether looking at one disability or the combined effects of all of the service-connected disabilities, extraschedular referral is not warranted absent the presence of governing norms, such as marked interference with employment or frequent hospitalizations. See 38 C.F.R. § 3.321(b)(1). Such is not present in this case when looking solely at the service-connected bilateral hearing loss or when looking at the combined service-connected disabilities. The Veteran has not alleged and the record does not support a finding that he has frequently been hospitalized as a result of his service-connected disabilities, to include his hearing loss. The Veteran's service-connected disabilities certainly have an effect on his ability to work. However, this is reflected by the combined rating currently assigned. The Veteran has not described problems with employment due to the combination of his disabilities nor does the record otherwise reveal such problems. Regarding hearing loss, the Veteran reports needing to look at people when they talk, certain noises bothering him, and problems hearing with background noise. He has not revealed any employment related issues as a result of these problems. Marked interference with employment above that already accounted for by the currently assigned combined disability rating, or the noncompensable rating assigned for hearing loss, is not present. No other situation akin to the demonstrative governing norms is shown by the evidence of record to include the lay statements. Simply put, the Veteran's bilateral hearing loss alone, and the Veteran's service-connected disabilities in combination, do not present an exceptional or unusual disability picture. ORDER Entitlement to service connection for right mid forehead scar is granted. Entitlement to service connection for a back disability is denied. Entitlement to service connection for a headache disability is denied. Entitlement to an initial compensable evaluation for bilateral hearing loss is denied. REMAND The Veteran was afforded neck and peripheral neuropathy VA examinations in November 2012. The same examiner, a nurse practitioner, performed both of the examinations. The examiner ultimately determined that he could not resolve the issue of etiology of the cervical spine disability and peripheral neuropathy without resorting to mere speculation. In Jones v. Shinseki, 23 Vet. App. 382, 390 (2010), the Court held that before relying on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the review of the evidence. In this case, the examiner stated that he had no objective evidence to support that the conditions were chronic or aggravated above what is expected with normal progression and aging/degenerative joint disease. It is somewhat unclear to the Board why, in light of the evidence already on file, the nurse practitioner could not offer an opinion. As such these issues must be remanded so that a physician can review the file and determine if an opinion can be offered based on the evidence already of record. On remand, the Veteran will be afforded the opportunity to identify any relevant records not already in VA's possession. By way of background, service treatment records reflect that in October 1966, after playing basketball, the Veteran awoke with pain on certain movements in the left subscapular area. Examination was normal and the impression was mild muscle strain. In February 1967, the Veteran had pain the right scapular area due to a fall. He was assessed with muscle aches. Musculoskeletal, spinal, and neurological examinations were normal in July 1967, July 1968, June 1969, and November 1969. The emergency room report regarding the Veteran's motor vehicle accident noted pain in multiple areas but not the neck. Instead, the Veteran denied neck pain at that time. During an August 1987 VA neuropsychiatric evaluation, it was noted that the Veteran had a slight tremor to his extended fingers, but nothing to indicate reflex, sensory, or motor disturbances. November 2010 cervical X-rays showed degenerative changes and nerve conduction studies that month were suggestive of peripheral neuropathy. After examination in November 2012, the Veteran was diagnosed with cervical strain with radiculopathy at the left trapezius and left 4th and 5th fingers, degenerative changes, and neuroforaminal narrowing; as well as peripheral neuropathy. A January 2013 cervical spine MRI demonstrated, at C6-7, uncovertebral and facet joint hypertrophy with mild bilateral foraminal narrowing. In light of the evidence suggesting that the Veteran may have peripheral neuropathy of the upper extremities as a result of a cervical spine disability, and the Veteran's contention that the cervical spine disability is related to service, notice regarding substantiating a claim for service connection on a secondary basis should be sent to the Veteran. Regarding the claim for service connection for an acquired psychiatric disorder, the Board finds that additional records development and examination are warranted. A June 1969 service treatment record reflects that the Veteran sought treatment at the mental health clinic in Ft. Hood. Likewise, at separation in November 1969 it was noted that the Veteran was seen by a psychiatrist at that time for nervous trouble, depression, and excessive worry. These potentially relevant records have not been obtained and should be requested on remand. In addition, the VA examinations in this case - performed in December 2010 and November 2012 - both found that the Veteran did not meet the criteria for PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). However, the new version of the DSM, the DSM-5, is applicable to the Veteran's claim. See 38 C.F.R. §§ 4.125, 4.130 (2015); see also 80 Fed. Reg. 14308 (Mar. 19, 2015) (change applicable to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014). As such, the Veteran should be afforded another examination to determine if he has PTSD or other acquired psychiatric disorders based on the DSM-5 criteria. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify any outstanding treatment records from VA, Federal, or private facilities relevant to these claims. With the Veteran's assistance (such as providing contact information, dates of treatment, and authorization to obtain private records) identified records should be obtained. 2. Obtain mental health records from the Veteran's periods of military service. Specifically, service treatment records suggest the Veteran was treated by a psychiatrist and sought treatment at the Ft. Hood mental health clinic. 3. Provide the Veteran with notice consistent with a claim for service connection on a secondary basis. 4. After the above has been accomplished, schedule the Veteran for a VA psychiatric examination. The claim file must be made available to and be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted and the results reported. The examiner should elicit a full history from the Veteran and consider the lay statements of record. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Following review of the claims file and examination of the Veteran, the examiner should address the following. (a) What current psychiatric disorders, using DSM-5, does the Veteran have? (b) If the Veteran has PTSD by DSM-5 standards, please list all stressful events contributing to that diagnosis. (c) For all other diagnosed psychiatric disorders, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the each diagnosed disorder arose during service or is otherwise related to service. A rationale for all opinions expressed should be provided. 5. After the development outlined in paragraphs (1) through (3) has been accomplished, send the claims file to a physician to address the following question after review of the record. Is it at least as likely as not (50 percent probability or greater) that any current cervical spine disability is related to the Veteran's military service, to include the motor vehicle accident in 1969? It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the physician should provide a fully reasoned explanation. A complete rationale for all opinions expressed should be provided. If the physician determines that an examination of the Veteran is necessary to provide the requested opinion, then such should be scheduled. 6. After the development outlined in paragraphs (1) through (3) has been accomplished, send the claims file to a physician to address the following questions after review of the record. (a) Is it at least as likely as not (50 percent probability or greater) that any current peripheral neuropathy (or similar disorder) of the upper or lower extremities is related to the Veteran's military service, to include the motor vehicle accident in 1969? (b) Is it at least as likely as not (50 percent probability or greater) that any current peripheral neuropathy (or similar disorder) of the upper extremities was caused by or aggravated by (permanently worsened) the Veteran's current cervical spine disability? It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the physician should provide a fully reasoned explanation. A complete rationale for all opinions expressed should be provided. If the physician determines that an examination of the Veteran is necessary to provide the requested opinion, then such should be scheduled. 7. Then, review the record again. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a supplemental statement of the case and be given the opportunity to respond thereto. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs