Citation Nr: 1600879 Decision Date: 01/11/16 Archive Date: 01/21/16 DOCKET NO. 10-31 290 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for a kidney disorder, to include chronic renal insufficiency, as secondary to diabetes mellitus. 3. Entitlement to service connection for high cholesterol. 4. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus. 5. Entitlement to service connection for primary open angle glaucoma as secondary to diabetes mellitus. 6. Entitlement to an initial rating higher than 20 percent for diabetes mellitus. 7. Entitlement to an initial compensable rating for erectile dysfunction. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran served on active duty from July 1968 to July 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2015, the Veteran testified at a Travel Board hearing before the undersigned. A transcript of that hearing is of record. At the hearing and in September 2015 the Veteran submitted additional evidence and waived the right to have the RO initially consider it. 38 C.F.R. §§ 20.800, 20.1304 (2015). The issue of whether new and material evidence has been received to reopen a claim for entitlement to service connection for a heart disability as secondary to exposure to herbicides has been raised by the record in a September 14, 2015 statement, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). The claims for service connection for hypertension and primary open angle glaucoma are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. After resolving doubt in the Veteran's favor, the evidence indicates that the Veteran's tinnitus at least as likely as not had its onset in service. 2. The evidence of record is in equipoise as to whether the Veteran's kidney disorder, to include chronic renal insufficiency, was caused by his service-connected diabetes mellitus. 3. High cholesterol is a laboratory finding and not a chronic disability for which VA disability benefits may be awarded. 4. The Veteran's diabetes mellitus is controlled with oral medication and diet; and insulin or regulation of activities is not required. 5. At his July 2015 Travel Board hearing, prior to the promulgation of a decision by the Board, the Veteran withdrew from appellate review his claim for an initial compensable rating for erectile dysfunction. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for tinnitus have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 2. The requirements for establishing service connection for kidney disorder, to include chronic renal insufficiency, have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). 3. The criteria for the establishment of service connection for high cholesterol have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). 4. The criteria for an initial rating greater than 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. § 3.102, 4.3, 4.7, 4.21, 4.119, Diagnostic Code 7913 (2015). 5. The criteria for withdrawal of the claim for an initial compensable rating for erectile dysfunction have been met. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 20.202, 20.204 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist a claimant in the development of a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). Compliant VCAA notice was provided by correspondence in August 2008 and February 2009. Concerning the claim for a higher rating for diabetes mellitus, the appeal arises from the initial award of service connection. In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court 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, 19 Vet. App. at 490-91; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (section 5103(a) notice is no longer required after service-connection is awarded); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Relevant to VA's duty to assist, the Agency of Original Jurisdiction (AOJ) made multiple attempts to obtain additional service records, specifically service treatment records for the period from July 1, 1968 to July 31, 1988, through official sources, but was informed by National Personnel Records Center that such records were not found or did not exist. The AOJ informed the Veteran that the records were not available and he was advised to submit any records he may have in his possession. The Board finds that additional efforts to obtain these records would be futile. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran including service personnel records, and post-service treatment records, and VA examination and opinion reports have been obtained, which are adequate upon which to base a determination. The Veteran was afforded a hearing before the Board, at which he presented oral testimony in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the person who chairs a hearing explain the issues and suggest the submission of evidence that may have been overlooked. Here, the undersigned identified the issues and the Veteran testified as to the events in service, symptomatology, and treatment history for his claimed conditions. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. The hearing focused on the elements necessary to substantiate the claims and the Veteran testified as to those elements. As such, the Board finds that there is no prejudice to the Veteran in deciding this case and that no further action pursuant to Bryant is necessary. Based on a review of the record, the Board finds that there is no indication that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board finds that the duty to notify and duty to assist have been satisfied and will proceed to review the merits of the issues on appeal. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). A disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2014); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 1. Tinnitus The Veteran asserts that he currently suffers from tinnitus that was incurred in service. Specifically, he reported military noise exposure from aircraft noise while working on the flight line for approximately 20 years, as well as from shell fire while stationed in Vietnam. At his hearing the Veteran asserted that he initially experienced ringing in his ears in service, and it continued throughout the years. After a careful review of the claims folder, the Board finds that the competent and credible evidence of record establishes that the Veteran's tinnitus as likely as not had its onset in service. The Veteran is competent to state that his tinnitus began during service, because tinnitus is capable of lay observation. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). Tinnitus is, by definition, "a noise in the ears, such as ringing, buzzing, roaring, or clicking. It is usually subjective in type." See Dorland's Illustrated Medical Dictionary 1914 (30th ed. 2003). Because tinnitus is "subjective," its existence is generally determined by whether or not the Veteran claims to experience it. Accordingly, lay testimony is competent to establish the presence and onset of tinnitus. Charles, supra; Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). Service personnel records indicate that the Veteran served in the Airforce and his military occupational specialties included mobile refueling operator, fuel specialist, DDA mobile refueling operator, and fuel supervisor. In support of his claim, the Veteran submitted two June 2009 witness statements from fellow service members who reported having served with the Veteran at Carswell Air Force Base in Texas, from approximately 1984 to 1988, and reported that they worked with the Veteran on the flight line refueling aircrafts which exposed them to excessive noise on a daily basis. The Board finds that noise exposure is consistent with the conditions and circumstances of the Veteran's service and is, therefore, deemed credible. Thus the Board acknowledges in-service acoustic trauma. As previously noted, the service treatment records are incomplete. Although there was no documentation of tinnitus in service, the Veteran is competent to testify that he first experienced tinnitus during service. In this regard, on VA audiological consultation in February 2009, the Veteran reported onset of tinnitus after military service, approximately 15 years earlier. He also endorsed a history of occupational noise exposure as a civilian. Therefore, the examiner opined that the Veteran's tinnitus was less likely as not related to military service. However, in a statement in October 2012, the Veteran's private treating audiologist noted the Veteran's noise exposure in service from aircraft engine noise and shelling while stationed in Vietnam. Reportedly, the Veteran experienced chronic and constant subjective tinnitus that began while in the service, but he did not seek medical treatment initially because he believed the ringing in his ears was a normal occurrence. Accordingly, based on the Veteran's competent and credible report of noise exposure in the military, the audiologist opined that it was at least as likely as not that his chronic and constant tinnitus was contributed to by noise exposure experienced during his military service. The mandate to accord the benefit of the doubt is triggered when the evidence has reached a stage of balance. In this matter, the Board is of the opinion that this point has been attained, based on the Veteran's competent and credible report of tinnitus beginning in service and since service, as well as the positive and negative medical evidence, one of which is a competent medical statement that supports the Veteran's contentions; that is, the October 2012 private audiologist's report which attributes his tinnitus to service. Additionally, the Veteran's lay assertions that his tinnitus began during service are of probative value. Because a state of relative equipoise has been reached in this case, the benefit of the doubt rule will therefore be applied. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Brown v. Brown, 5 Vet. App. 413, 421 (1993). Accordingly, service connection for tinnitus is warranted. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Kidney disorder The Veteran claims entitlement to service connection for a kidney disorder as secondary to service connected diabetes mellitus. The evidence shows that the Veteran has been diagnosed with a kidney disorder, to include renal insufficiency. Having determined that the Veteran has a current disability, the remaining question before the Board is whether there is nexus between the current disability and his service or a service-connected disability. The service treatment records contain no complaints, history or findings consistent with kidney disease. After service, private treatment records after 2008 document treatment for kidney stones, renal cysts, and renal insufficiency. Accordingly, service connection on a direct basis is not established. The thrust of the Veteran's claim is that his kidney disease is secondary to his service-connected diabetes mellitus. Thus, the determinative question in this case is whether his kidney disorder is caused or aggravated by his service-connected diabetes mellitus. On this point, the Board finds that the evidence is at least in equipoise regarding the Veteran's claim of entitlement to service connection for a kidney disorder as secondary to his service-connected diabetes mellitus. 38 C.F.R. § 3.310 (2015). In a June 2009 statement, Dr. M.J., the Veteran's private treating nephrologist, indicated that although he initially thought the Veteran had hypertensive nephropathy, testing was consistent with diabetic nephropathy. A VA examiner in May 2010, diagnosed stage III chronic kidney disease more likely than not secondary to his hypertension with nephrosclerosis, as opposed to diabetes mellitus. However, a different VA examiner in March 2012, opined that the Veteran suffered from diabetic nephropathy or renal dysfunction caused by diabetes mellitus. Finally, in August 2015, Dr. M.J. noted treatment for hypertensive nephrosclerosis. Resolving all reasonable doubt in the Veteran's favor, the weight of the competent and credible medical evidence demonstrates a nexus between the Veteran's current kidney disorder and diabetes mellitus. Therefore, service connection a kidney disorder as secondary to diabetes mellitus, is granted. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102; Gilbert, supra. 3. High cholesterol The Veteran is currently being treated for high cholesterol. Based on a thorough review of the record, the Board finds that the preponderance of the evidence is against service connection for high cholesterol. High cholesterol is not a disability for VA purposes. High cholesterol is also referred to as hypercholesterolemia or hyperlipidemia. Hypercholesterolemia is an "excess of cholesterol in the blood." Dorland's Illustrated Medical Dictionary 792 (28th ed. 1994). Hyperlipidemia is "a general term for elevated concentrations of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia, etc." Id. at 795. Hyperlipidemia and elevated cholesterol are laboratory findings and are not disabilities in and of themselves for which VA compensation benefits are payable. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (Diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule.) The term "disability" as used for VA purposes refers to impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). There is no evidence of record suggesting the Veteran's elevated cholesterol or hyperlipidemia causes any impairment of earning capacity. Again, the Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Brown, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection can only be granted for a disability resulting from disease or injury. See 38 U.S.C.A. § 1110. High cholesterol is a laboratory finding that manifests itself only in laboratory test results and is not a disability for which service connection can be granted. As such, service connection for high cholesterol is not warranted. In sum, the evidence demonstrates that the Veteran is not entitled to service connection for high cholesterol. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Increased Rating 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; 38 C.F.R. § 4.1. 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; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; 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; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Diabetes mellitus is currently rated 20 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code 7913. The 20 percent evaluation encompasses requiring insulin and restricted diet, or; oral hypoglycemic agent and a restricted diet. The criteria for 40 percent under Diagnostic Code 7913 are insulin dependence, restricted diet, and regulation of activities. The criteria for 60 percent are that the Veteran requires insulin, a restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. Note (1) to Diagnostic Code 7913 provides that compensable complications of diabetes are rated separately unless they are part of the criteria used to support a 100 percent evaluation. Note 2 provides that when diabetes mellitus has been conclusively diagnosed, do not request a glucose tolerance test solely for rating purposes. Competent medical evidence is required to establish "regulation of activities," namely, avoidance of strenuous occupational and recreational activities, for a 40 percent rating under Diagnostic Code 7913. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). The Veteran contends that he is entitled to a rating higher than 20 percent for diabetes mellitus. At the July 2015 personal hearing, he testified that diabetes mellitus adversely affected his quality of life because he would easily tire and sometimes he would take time off from work. Reportedly, he was employed as a truck driver and also performed warehouse type work. He denied ever having any requirement for insulin. On VA diabetes mellitus examination in February 2009, the examiner noted a diagnosis of diabetes mellitus, type II, in 1990-91. The Veteran's private physician started him on oral agents at the time, along with diet and exercise. The Veteran had never been prescribed insulin. At the time of the examination, treatment consisted of Metformin 500 mg two twice a day. The Veteran had never been hospitalized for diabetes, ketoacidosis, or hypoglycemia. The examiner noted that the Veteran was employed as a truck driver and his diabetes mellitus did not interfere with his occupation or daily activities. On VA diabetes mellitus examination in May 2010, the examiner noted that the Veteran was being treated for diabetes mellitus with oral agents. He continued to take Metformin 500 mg two tablets twice a day and walked half a mile three times a week. The Veteran denied restricted activity. He sought treatment every three to six months. There was no history of restricted diet, hospitalization for ketoacidosis or hypoglycemic reactions, or restriction of activity on account of diabetes. The diagnosis was type II diabetes mellitus managed with daily oral medication. On VA examination in March 2012, the examiner noted diabetes mellitus managed by prescribed oral hypoglycemic agents. The examiner indicated that the Veteran did not require insulin or regulation of activities as part of medical management of diabetes mellitus. He was followed less than twice per month. There were no episodes of ketoacidosis or hypoglycemic reactions. It was determined that his diabetes mellitus had no occupational impact. In sum, the evidence shows that the Veteran has never been required to take insulin or required to regulate his activities. Thus, although the Veteran's testimony seems to suggest that he has somewhat limited his activities because he is easily fatigued, he also testified that he engages in an exercise regimen. Moreover, the avoidance of strenuous occupational and recreational activities has not been established by the medical evidence, as no health-care provider had instructed the Veteran to avoid strenuous occupational and recreational activities. The Board has considered the evidence and his testimony as to his use of oral medication, as well as the affect of his diabetes on his activities of daily living and occupationally. Nevertheless, the criteria for a rating in excess of 20 percent for diabetes have not been met. In this case, for the reasons shown and explained, the preponderance of the evidence is against the claim for a rating in excess of 20 percent for diabetes and, so, there is doubt to be resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed.Cir. 2001). Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2015). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b)(1) (2015). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations are inadequate. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Other elements are marked interference with employment or frequent periods of hospitalization. Addressing the adequacy of the scheduler rating criteria requires a comparison between the level of severity and symptomatology of the Veteran's service-connected disabilities with the criteria in the Rating Schedule. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule and the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the schedular evaluation assigned for the Veteran's service-connected diabetes is adequate in this case. There is no persuasive evidence of occupational or functional impairment due to diabetes which is not already contemplated by the potentially applicable schedular criteria. Further, the rating criteria otherwise adequately describe the severity and symptomatology of the Veteran's service-connected diabetes. Here, there is no suggestion or contention that the diabetes, cumulatively or collectively with the service-connected post-traumatic stress disorder, peripheral neuropathy of the lower and upper extremities, and erectile dysfunction, causes marked interference with employment or required frequent hospitalizations. Thus, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); see also Johnson v. McDonald, 762 F3d. 1362; 2014 WL 3844196 (C.A. Fed.); No. 2013-7104, slip op. (Fed. Cir. Aug. 6, 2014) overruling Johnson v. Shinseki, 26 Vet. App. 237, 248 (2013). Withdrawal of appeal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2014). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2015). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. At his Board hearing in July 2015, the Veteran withdrew the issue of an initial compensable rating for erectile dysfunction from appellate consideration. The transcript of the hearing has been reduced to writing and is of record. Thus, the Veteran has withdrawn this appeal and, hence, there remain no allegations of errors of fact or law for appellate consideration on this issue. Accordingly, the Board does not have jurisdiction to review the appeal on this issue and it is dismissed. ORDER Service connection for tinnitus is granted. Service connection for a kidney disorder as secondary to diabetes mellitus is granted. Entitlement to service connection for high cholesterol is denied. An initial rating in excess of 20 percent for diabetes mellitus is denied. The appeal concerning the claim for an initial compensable rating for erectile dysfunction is dismissed. REMAND The Veteran claims entitlement to service connection for hypertension, and primary open angle glaucoma, as secondary to service-connected diabetes mellitus. He also asserts that hypertension had onset in service. After a review, the Board observes that further development is required prior to adjudicating the Veteran's claims. Service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. Service connection may also be established for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). However, service connection not be awarded on an aggravation basis without the establishment of a pre-aggravation baseline level of disability which can be compared to the current level of disability. Pre-aggravation baseline level of disability should be established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the non-service-connected disease. 38 C.F.R. § 3.310 (2015). Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002). While VA obtained medical examinations and opinions pertaining to the claims for service connection for hypertension and primary open angle glaucoma, the medical opinions of record did not address the question concerning aggravation beyond natural progression. Therefore, the Board finds a remand is required to obtain such opinions. On remand, relevant ongoing medical records should also be requested. Accordingly, the case is REMANDED for the following actions: 1. Request the Veteran to identify all medical providers (VA and private) from whom he has received treatment for hypertension and primary open angle glaucoma, and complete and return an appropriate authorization form for each treatment provider identified. After obtaining the completed release form, request all identified pertinent medical records. All development efforts should be associated with the claims file. If the requested records cannot be obtained, the Veteran should be notified of such. 2. Obtain all VA treatment records, if any, not already in the claims file. 3. Thereafter, schedule the Veteran for a VA eye examination to address the claim for service connection for the primary open angle glaucoma. The claims file and electronic treatment records must be thoroughly reviewed by the examiner in connection with the examination. All tests and studies deemed necessary should be conducted and all findings should be reported in detail. Following review of the claims file and examination of the Veteran, the examiner should respond to the following: a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's primary open angle glaucoma was caused by the service-connected diabetes mellitus? Please explain why or why not. b) If not caused by diabetes mellitus, is it at least as likely as not (50 percent or greater probability) that the Veteran's primary open angle glaucoma was permanently worsened beyond the natural progress of the condition (versus temporary exacerbation of symptoms) by the service-connected diabetes mellitus? Please explain why or why not. c) If the Veteran's primary open angle glaucoma was permanently worsened beyond the natural progress of the condition (aggravated), the examiner should attempt to determine the level of aggravation beyond baseline. 4. After the development in 1&2 has been completed, schedule the Veteran for VA examination to address the claim for service connection for hypertension. The claims file and electronic treatment records must be thoroughly reviewed by the examiner in connection with the examination. All tests and studies deemed necessary should be conducted and all findings should be reported in detail. Following review of the claims file, the Veteran's statements regarding the development and treatment of his claimed disorder, and an examination of the Veteran, the examiner should respond to the following: a) Is it at least as likely as not (50 percent probability or greater) that hypertension had its onset in service or within one year following the Veteran's discharge from service in July 1988? If so, the examiner should describe the manifestations. b) If not, is it at least as likely as not (50 percent or greater probability) that hypertension is caused by the service-connected diabetes mellitus? Please explain why or why not. c) If not caused by diabetes mellitus, is it at least as likely as not (50 percent or greater probability) that hypertension was permanently worsened beyond the natural progress of the condition (versus temporary exacerbation of symptoms) by the service-connected diabetes mellitus? Please explain why or why not. d) If hypertension was permanently worsened beyond the natural progress of the condition (aggravated), the examiner should attempt to determine the level of aggravation beyond baseline. 5. After the above development is completed, if the benefits sought on appeal remain denied, the Veteran and his representative should be issued a supplemental statement of the case and be provided an appropriate opportunity to respond, before the case is returned to the Board. 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 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). ______________________________________________ S. HENEKS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs