Citation Nr: 1603206	
Decision Date: 02/01/16    Archive Date: 02/11/16

DOCKET NO.  10-03 202	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina


THE ISSUES

1.  Entitlement to service connection for erectile dysfunction, including as secondary to degenerative disc disease of the lumbar spine. 

2.  Entitlement to a disability rating higher than 10 percent for hearing loss.

3.  Entitlement to a disability rating higher than 10 percent for tenosynovitis of the right wrist.

4.  Entitlement to a disability rating higher than 10 percent for tenosynovitis of the left wrist.

5.  Entitlement to a disability rating higher than 20 percent for degenerative disc disease of the lumbar spine.

6.  Entitlement to an initial disability rating in excess of 10 percent for radiculopathy of the right lower extremity.

7.  Entitlement to an initial disability rating in excess of 10 percent for radiculopathy of the left lower extremity.

8.  Entitlement to an effective date earlier than May 12, 2014, for the grant of service connection for radiculopathy of the right lower extremity.

9.  Entitlement to an effective date earlier than May 12, 2014, for the grant of service connection for radiculopathy of the left lower extremity.

10.  Whether new and material evidence has been received to reopen a claim for service connection for plantar fasciitis of the right foot.

11.  Entitlement to service connection for flat feet.

12.  Entitlement to an initial disability rating in excess of 10 percent for folliculitis with eczema.

13.  Entitlement to an effective date earlier than May 8, 2008, for the grant of service connection for folliculitis with eczema.

14.  Entitlement to an initial compensable disability rating for umbilical hernia.

15.  Entitlement to an initial disability compensable rating for inguinal hernia.


WITNESS AT HEARING ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

C. Fleming, Counsel


INTRODUCTION

The Veteran had active military service from June 1972 to June 2000.

These matters come before the Board of Veterans' Appeals (Board) on appeal from December 2008, August 2012, and June 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina.  In the December 2008 decision, the RO denied the Veteran's claim for an increased rating for degenerative disc disease of the lumbar spine.  In the August 2012 decision, the RO denied the Veteran's claim for service connection for erectile dysfunction and his claims for increased ratings for hearing loss and tenosynovitis of the wrists.  Additionally, in the June 2014 decision, the RO granted service connection for radiculopathy of the right and left lower extremities, assigning initial 10 percent ratings for each extremity and assigning an effective date of May 12, 2014.

The Board remanded the lumbar spine issue in February 2013 for further evidentiary development and adjudication.  In that remand, the Board instructed the agency of original jurisdiction (AOJ) to obtain additional VA examination and then re-adjudicate the claim.  The Board also instructed the AOJ to provide a statement of the case for the tenosynovitis, hearing loss, and erectile dysfunction claims.  The AOJ obtained VA examination in May 2014 and provided the Veteran a supplemental statement of the case (SSOC) concerning the lumbar spine claim in February 2015.  The AOJ also issued the required statement of the case in November 2014.  Thus, there has been compliance with the Board's remand instructions.  See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance).

The Veteran presented testimony at a personal hearing before a Veterans Law Judge in October 2012.  A transcript is of record.  The law requires that the Veterans Law Judge who conducts a hearing on an appeal must participate in any decision made on that appeal.  38 U.S.C.A. § 7107(c) (West 2014); 38 C.F.R. § 20.707 (2015).  In November 2015, the Board sent a letter to the Veteran, which explained that the Veterans Law Judge who presided over his hearing was no longer available to participate in the appeal and offered the Veteran a hearing before a different Veterans Law Judge; otherwise, the case would be reassigned.  In December 2015, the Veteran responded that he did not want another hearing.  Thus, the Board will proceed with the matter on appeal.

The issues of entitlement to service connection for erectile dysfunction; whether new and material evidence has been received to reopen a claim for service connection for plantar fasciitis of the right foot; entitlement to service connection for flat feet; entitlement to an initial disability rating in excess of 10 percent for folliculitis with eczema; entitlement to an effective date earlier than May 8, 2008, for the grant of service connection for folliculitis with eczema; and entitlement to initial compensable disability ratings for umbilical hernia and inguinal hernia are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ.


FINDINGS OF FACT

1.  The Veteran's bilateral hearing loss has been manifested by auditory acuity no worse than Level I in each ear.

2.  Tenosynovitis of the right wrist has been manifested by subjective complaints of pain and objective findings of arthritis; no compensable limitation of motion or ankylosis of the wrist has been demonstrated.

3.  Tenosynovitis of the left wrist has been manifested by subjective complaints of pain and objective findings of arthritis; no compensable limitation of motion or ankylosis of the wrist has been demonstrated.

4.  Degenerative disc disease of the lumbar spine has been manifested by forward flexion of the lumbar spine limited to no worse than 60 degrees with pain on motion; ankylosis of the spine has not been shown.

5.  Radiculopathy of the right lower extremity has been manifested by symptoms of pain and numbness approximating no worse than mild incomplete paralysis of the sciatic nerve.

6.  Radiculopathy of the left lower extremity has been manifested by symptoms of intermittent pain approximating no worse than mild incomplete paralysis of the femoral nerve.

7.  Radiculopathy of the right sciatic nerve was first identified by a private physician on July 21, 2010; no prior diagnosis of any right lower extremity radiculopathy is present in the record.

8.  Radiculopathy of the left femoral nerve was first identified at a VA examination conducted on May 12, 2014; no prior diagnosis of any left lower extremity radiculopathy is present in the record.


CONCLUSIONS OF LAW

1.  The criteria for an initial disability rating in excess of 10 percent for bilateral hearing loss have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100 (2015).

2.  The criteria for a disability rating higher than 10 percent for tenosynovitis of the right wrist have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024, 5215 (2015).

3.  The criteria for a disability rating higher than 10 percent for tenosynovitis of the left wrist have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. 

§§ 3.159, 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024, 5215 (2015).

4.  The criteria for a rating higher than 20 percent for degenerative disc disease of the lumbar spine have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5237 (2015). 

5.  The criteria for an initial rating in excess of 10 percent for radiculopathy of the right lower extremity have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.124a, Diagnostic Code 8520 (2015).

6.  The criteria for an initial rating in excess of 10 percent for radiculopathy of the left lower extremity have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.124a, Diagnostic Code 8526 (2015).

7.  The criteria for an effective date of July 21, 2010, for the award of service connection for radiculopathy of the right lower extremity have been met.  38 U.S.C.A. §§ 5107, 5110 (West 2014); 38 C.F.R. §§ 3.400, 4.71a (2015).

8.  The criteria for an effective date prior to May 12, 2014, for the award of service connection for radiculopathy of the left lower extremity have not been met.  38 U.S.C.A. §§ 5107, 5110 (West 2014); 38 C.F.R. §§ 3.400, 4.71a (2015).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant.  38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002).

The Court's decision in Pelegrini v. Principi, 17 Vet. App. 412 (2004), held, in part, 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 a claim for VA benefits.  This decision has since been replaced by Pelegrini v. Principi, 18 Vet. App. 112 (2004), in which the Court continued to recognize that typically 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 a claim for VA benefits.

In June 2008 and January 2012, prior to the issuance of the rating decisions on appeal, the Veteran was issued VCAA notice pertaining to his claims.  These letters predated the rating decisions on appeal.  The VCAA letters notified the Veteran of what information and evidence is needed to substantiate his claims, the information and evidence that must be submitted by the claimant, what information and evidence will be obtained by VA, and the types of evidence necessary to establish an effective date.  Id.; but see VA O.G.C. Prec. Op. No. 1-2004 (Feb. 24, 2004); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).

The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way.  See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004).  In any event, the Veteran has not demonstrated any prejudice with regard to the content of any notice.  See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.)  See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006).

The Board also finds that VA has complied with all assistance provisions of the VCAA.  D'Aries v. Peake, 22 Vet. App. 97, 105 (2008).  The evidence of record contains the Veteran's service treatment records and lay statements of the Veteran, as well as post-service treatment from both private and VA treatment providers.  The evidence of record contains reports of examinations requested by VA performed in October 2008, September 2011, March 2012, December 2013, and May 2014.  Such examination reports, when taken together, are thorough and contain sufficient information to adjudicate the issues decided herein.  McLendon v. Nicholson, 20 Vet. App. 79 (2006).  

For all the foregoing reasons, the Board concludes that VA's duties to the Veteran have been fulfilled with respect to the issues decided herein.

Criteria & Analysis

The Veteran contends that his hearing loss is more disabling than reflected by the 10 percent disability rating initially assigned.  In addition, the Veteran contends that his tenosynovitis of the wrists is more disabling than reflected by the 10 percent disability ratings currently assigned for each wrist and that his degenerative disc disease of the lumbar spine is more disabling than the 20 percent rating currently assigned.  The Veteran further contends that his radiculopathy of the lower extremities is more disabling than reflected by the 10 percent disability ratings initially assigned for each lower extremity, and that the effective date for the award of service connection for radiculopathy of the lower extremities should be earlier than May 12, 2014.

Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2015).  When a question arises as to which of two ratings applies under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7 (2015).  After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran.  38 C.F.R. § 4.3 (2015).

The Veteran's entire history is reviewed when making disability evaluations.  See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995).  Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern.  See Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a staged rating is required.  See Fenderson v. West, 12 Vet. App. 119, 126 (1999).  Where entitlement to compensation has already been established, VA must address the evidence concerning the state of the disability from the time period one year before the claim for an increase was filed until VA makes a final decision on the claim.  The Court has held that consideration of the appropriateness of a staged rating is required.  See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007).

When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases in which the Veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use).  See 38 C.F.R. §§ 4.40, 4.45 (2015); DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995).  The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion.  Johnson v. Brown, 9 Vet. App. 7 (1996).  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.  In VA Fast Letter 06-25 (November 29, 2006), VA's Compensation and Pension Service noted that to properly evaluate any functional loss due to pain, examiners, at the very least, should undertake repetitive testing (to include at least three repetitions) of the joint's range of motion, if feasible.  It was determined that such testing should yield sufficient information on any functional loss due to an orthopedic disability.

Turning first to the Veteran's hearing loss claim, the Boards notes that hearing loss has been evaluated under Diagnostic Code 6100.  The assigned evaluation for hearing loss is determined by mechanically applying the rating criteria to certified test results.  See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992).  Under Diagnostic Code 6100, ratings for hearing loss are determined in accordance with the findings obtained on audiometric examination.  Evaluations of hearing impairment range from noncompensable 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 as measured by pure tone audiometry tests in the frequencies 1,000; 2,000; 3,000; and 4,000 Hertz (cycles per second).  To evaluate the degree of disability from hearing impairment, the rating schedule establishes eleven auditory acuity levels designated from Level I for essentially normal acuity through Level XI for profound deafness.  38 C.F.R. § 4.85, Diagnostic Code 6100.  As set forth in the regulations, Tables VI, VIa, and VII are used to calculate the rating to be assigned.  See 38 C.F.R. § 4.85, Diagnostic Code 6100.  Hearing tests will be conducted without hearing aids, and the results of above-described testing are charted on Table VI and Table VII.  See 38 C.F.R. § 4.85.  

Alternatively, VA regulations provide that in cases of exceptional hearing loss, when the pure tone thresholds at each of the four specified frequencies (1,000, 2,000, 3,000 and 4,000 Hertz) is 55 decibels or more, 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.  Each ear will be evaluated separately. 38 C.F.R. § 4.86(a).  The provisions of 38 C.F.R. § 4.86(b) further provide that, when the pure tone threshold is 30 decibels or less at 1,000 Hertz, and 70 decibels or more at 2,000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever would result in the higher numeral.

Relevant evidence of record consists of reports of VA examinations provided to the Veteran in March 2012, December 2013, and May 2014, as well as records of the Veteran's ongoing treatment by VA treatment providers.  Results from the March 2012 audiogram reflect that puretone thresholds, in decibels, were as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
25
25
20
35
45
LEFT
25
25
35
35
40

Puretone averages were 31.25 decibels for the right ear and 33.75 decibels for the left ear.  Speech audiometry revealed speech recognition ability of 90 percent bilaterally, using Maryland CNC tests.  At that time, the Veteran denied that his hearing loss had any functional impact on his work or his activities of daily living.  Based on those results with the utilization of Table VI, the Veteran has Level I hearing impairment in the right ear and Level I hearing impairment in the left ear.  Applying the results to Table VII, a noncompensable disability rating is warranted for hearing loss based on the March 2012 VA examination.  38 C.F.R. § 4.85 (Diagnostic Code 6100).

Results from the December 2013 audiogram reflect that puretone thresholds, in decibels, were as follows:





HERTZ



500
1000
2000
3000
4000
RIGHT
50
40
40
60
65
LEFT
40
30
35
60
60

Puretone averages were 51.25 decibels for the right ear and 46.25 decibels for the left ear.  Speech audiometry revealed speech recognition ability of 92 percent bilaterally, using Maryland CNC tests.  At that time, the Veteran denied that his hearing loss had any functional impact on his work or his activities of daily living.  Based on those results with the utilization of Table VI, the Veteran has Level I hearing impairment in the right ear and Level I hearing impairment in the left ear.  Applying the results to Table VII, a noncompensable disability rating is warranted for hearing loss based on the December 2013 VA examination.  Id. 

Results from the May 2014 audiogram reflect that puretone thresholds, in decibels, were as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
20
25
25
40
40
LEFT
25
20
15
35
45

Puretone averages were 32.5 decibels for the right ear and 28.75 decibels for the left ear.  Speech audiometry revealed speech recognition ability of 92 percent bilaterally, using Maryland CNC tests.  At that examination, the Veteran complained that the greatest difficulty posed by his hearing disorder was difficulty hearing his students speaking to him.  Based on those results with the utilization of Table VI, the Veteran has Level I hearing impairment in the right ear and Level I hearing impairment in the left ear.  Applying the results to Table VII, a noncompensable disability rating is warranted for hearing loss based on the May 2014 VA examination.  Id.

Records from the Veteran's ongoing treatment from VA providers also reflect that he has been noted on several occasions during the appeal period to experience hearing loss.  

Applying the results of the Veteran's March 2012, December 2013, and May 2014 VA audiograms reveals no worse than Level I hearing acuity in the right ear and Level I hearing acuity in the left ear.  Application of the above-noted findings to Table VII results in a noncompensable disability rating under 38 C.F.R. § 4.85, Diagnostic Code 6100.  At no time during the appeal period has the Veteran's hearing loss disability been shown to rise to the level of symptomatology required to support even a 10 percent disability rating.  Thus, the VA examination reports do not support the assignment of a disability rating higher than that currently assigned-a 10 percent rating-for the entirety of the appeal period.  

Turning to the claims for higher ratings for tenosynovitis of the wrists, the RO has rated these disorders under 38 C.F.R. § 4.71a, Diagnostic Codes 5024, governing tenosynovitis.  Under that Diagnostic Code, disorders are to be rated as limitation of motion of affected parts as degenerative arthritis, as set forth in 38 C.F.R. § 4.71a, Diagnostic Code 5003.  In turn, Diagnostic Code 5003 requires that arthritis be evaluated on the basis of limitation of motion, if compensably disabling based on the effect of arthritis on the affected joints.  When limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Diagnostic Codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003.  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.  In the absence of limitation of motion, Diagnostic Code 5003 provides that a 10 percent rating is for application with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups.  With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent rating is warranted.

Under rating criteria pertaining to limitation of motion of the wrist, Diagnostic Code 5215 provides that a maximum 10 percent rating is assigned for limitation of dorsiflexion of the major or minor wrist to less than 15 degrees, or limitation of palmar flexion in line with forearm.  38 C.F.R. § 4.71a (2015).  (The standardized range of motion for the wrist is plantar flexion to 80 degrees, dorsiflexion to 70 degrees, ulnar deviation to 40 degrees, and radial deviation to 20 degrees.  38 C.F.R. § 4.71, Plate I (2015)).

Relevant medical evidence consists of VA examination provided to the Veteran in March 2012.  Report of that examination reflects that the Veteran complained of pain and limited motion in his wrists, which increased with frequent use.  Physical examination revealed palmar flexion to 65 degrees bilaterally, with pain beginning at 60 degrees, and dorsiflexion to 60 degrees, with pain beginning at 55 degrees, and no additional limitations on repetition.  The Veteran was also noted to have localized tenderness or pain on palpation of the left wrist, although muscle strength was normal bilaterally.  The examiner specifically found the Veteran to have no ankylosis of either wrist.  Arthritis was found on x-ray, and the diagnosis was tenosynovitis and degenerative joint disease of the wrists.  

Upon review of the relevant evidence, the Board finds that the Veteran is currently in receipt of the maximum schedular rating under Diagnostic Code 5215.  To warrant a higher rating, ankylosis of the wrist or comparable impairment must be demonstrated.  38 C.F.R. § 4.71a, Diagnostic Codes 5214, 5215 (2015).  As no ankylosis, or comparable disability, has been demonstrated or found on examination at any time during the appeal period, the Board finds that the Veteran's tenosynovitis of the right and left wrists does not warrant ratings higher than the 10 percent currently assigned for each wrist.  Id.  

In so finding, the Board acknowledges the Veteran's reports of pain and flare ups but finds that the effects of pain are already contemplated by the 10 percent ratings assigned for each wrist.  The objective medical evidence indicates that although there is pain during motion and with repetitive movements, the pain does not limit the Veteran's motion to such a degree that it is tantamount to ankylosis.  See 38 C.F.R. §§ 4.40, 4.45 (2015); DeLuca, 8 Vet. App. 202.  The Board has considered the Veteran's contentions, but does not find that the evidence shows disability tantamount to ankylosis in light of the clinical findings of bilateral wrist movement.  Id.; Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995); 38 C.F.R. § 4.71a, Diagnostic Code 5214.  Further, the Board notes that absent a compensable level of limited motion, the highest rating available for arthritis of a major joint such as a wrist under Diagnostic Code 5003 is 10 percent.  In this case, the Veteran is currently assigned a 10 percent rating for each wrist on the basis of painful motion of the wrists.  Thus, higher ratings under Diagnostic Code 5003 on the basis of arthritis are not available.  See 38 C.F.R. § 4.71a, Diagnostic Code 5003.

Regarding the Veteran's degenerative disc disease of the lumbar spine and radiculopathy of the lower extremities, the RO has evaluated the Veteran's lumbar spine in accordance with the criteria set forth in the General Rating Formula for Diseases and Injuries of the Spine, 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2015).  Under the General Rating Formula for Diseases and Injuries of the Spine, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine.  A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine.  A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less, or, favorable ankylosis of the entire thoracolumbar spine.  A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.  38 C.F.R. § 4.71a, Diagnostic Code 5237.

Following the criteria set forth in the General Rating Formula for Diseases and Injuries of the Spine, Note (1) provides: evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code.

Note (2) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion.

Note (3) provides that in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted.

Note (4) requires that each range of motion measurement be rounded to the nearest five degrees.

Note (5) provides that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.

Note (6) provides that disabilities of the thoracolumbar and cervical spine segments must be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability.

In addition, intervertebral disc syndrome (preoperatively or postoperatively) may be evaluated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined.  The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides for a 20 percent disability rating with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months.  With incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months, a 40 percent evaluation is in order.  Finally, a maximum schedular rating of 60 percent is assigned for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months.

As for neurological disabilities, evaluations are assigned based on whether the paralysis of a particular nerve is complete or incomplete.  Here, the Veteran has been evaluated for radiculopathy of the right lower extremity under Diagnostic Code 8520, which addresses paralysis of the sciatic nerve.  38 C.F.R. § 4.124a (2015).  Under Diagnostic Code 8520, a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; a 60 percent rating is warranted for severe incomplete paralysis, with marked muscular atrophy; and an 80 percent rating is warranted for complete paralysis.  Complete paralysis consists of the foot dangling and dropping, with no active movement possible of the muscles below the knee and flexion of the knee weakened or lost.  38 C.F.R. § 4.124a, Diagnostic Code 8520.  Similarly, the Veteran has been evaluated for radiculopathy of the left lower extremity under Diagnostic Code 8526, which addresses paralysis of the femoral nerve.  Under Diagnostic Code 8526, a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 30 percent rating is warranted for severe incomplete paralysis; and a 40 percent rating is warranted for complete paralysis, which consists of paralysis of the quadriceps extensor muscles.  38 C.F.R. § 4.124a, Diagnostic Code 8526.

Relevant evidence of record consists of VA examinations conducted in October 2008, September 2011, and May 2014, as well as records of the Veteran's ongoing treatment with both private and VA treatment providers and his hearing testimony.  At the October 2008 VA examination, the Veteran complained of pain in his lumbar spine that radiated into his lower extremities and flared up with strenuous activity.  He reported that he used a cane to ambulate and wore a lumbosacral corset.  He further stated that he had experienced "a couple of incapacitating episodes" in the previous year that had caused him to miss work, totaling approximately two weeks.  Physical examination found range of motion of flexion to 70 degrees with pain on motion and no additional limitation on repetition.  No spasms, weakness, or tenderness was noted.  Neurological examination revealed negative straight-leg raising, normal deep tendon reflexes, and normal sensation and strength in the lower extremities bilaterally.  The examiner diagnosed lumbosacral strain; no diagnosis of radiculopathy or any other neurological disorder was assigned. 

Report of the September 2011 VA examination reflects that the Veteran reported having been previously diagnosed with "sciatica symptoms."  He complained of severe pain in his lumbar spine that caused limitation in walking and stated that he could walk on average a maximum of 200 yards.  He also stated that he had fallen several times due to his lumbar spine disability.  He complained of stiffness, muscle spasms, decreased motion, and tingling, pain, and numbness in the lower extremities.  He denied bladder and bowel problems.  He stated that he had experienced incapacitating episodes of three days in 2011 following trips to the emergency room.  Physical examination revealed a normal gait and posture, with a steady walk.  The examiner found forward flexion of the lumbar spine to be to 60 degrees, with pain at the endpoint of motion and no additional limitation on repetition.  Neurological examination revealed no sensory deficits or motor weakness, as well as normal reflexes and no signs of intervertebral disc syndrome.  The examiner diagnosed degenerative disc disease of the lumbar spine with sciatica.  

Report of the May 12, 2014, VA examination reflects that the Veteran complained of worsening pain in his back, along with soreness and stiffness that limited mobility during flare-ups.  In particular, the Veteran reported constant stiffness and pain in the back that was aggravated by physical activity.  Physical examination found flexion to 90 degrees, with pain beginning at 65 degrees.  The Veteran refused to engage in repetitive-motion testing.  No tenderness to palpation was noted, although the examiner found the Veteran to experience muscle spasm severe enough to cause an abnormal gait.  Muscle strength of the lower extremities was normal bilaterally, as were reflexes, with the exception of a decreased left knee reflex.  Sensory examination was also normal, although the Veteran complained of moderate constant pain and numbness on the right and of moderate intermittent pain on the left.  No other signs or symptoms of radiculopathy or any other neurological disorder were noted.  The examiner diagnosed the Veteran with mild degenerative joint disease of the lumbar spine and congenital lumbar stenosis but found him not to have intervertebral disc syndrome.  The examiner also diagnosed mild right sciatic radiculopathy and mild left femoral radiculopathy but noted that the Veteran had "no current left leg complaints."  

Records of the Veteran's ongoing treatment reflect that he has consistently sought treatment for his back problems in the years since his claim was filed.  Treatment records document that he visited the emergency room on multiple occasions from 2008 through 2011 for flare-ups of low back pain, which he reported radiated into his lower extremities.  He was seen in June 2010 for complaints of low back pain that radiated into his right lower extremity.  At that time, MRI study revealed multilevel degenerative joint disease.  On a July 2010 "Medical Statement," the Veteran's private physician indicated that the Veteran experienced incapacitating episodes of at least six weeks due to his lumbar spine disability.  He was diagnosed with right-sided sciatica at a private treatment visit on July 21, 2010; this diagnosis was confirmed by the same treatment provider in October 2013.  At his October 2012 hearing, the Veteran complained of lower back pain that prevented him from exercising and interfered with sleeping, sitting, standing, and lifting heavy loads.  At that time, he also complained of pain radiating into his legs.  He made similar complaints on an August 2010 statement, at which time he reported chronic pain in his lumbar spine that radiated into his lower extremities, as well as numbness, tingling, and burning in his legs.

Upon review of the above evidence, the Board finds that the Veteran's degenerative disc disease of the lumbar spine does not warrant a rating higher than the 20 percent currently assigned.  In this case, the Veteran's flexion of the thoracolumbar spine has been to no worse than 60 degrees with pain on motion, which does not warrant a 40 percent rating under the General Rating Formula for Diseases and Injuries of the Spine.  In particular, the Board notes, as discussed above, that at the October 2008 VA examination, he was noted to have flexion of the thoracolumbar spine to, at worst, 70 degrees with pain on motion.  Similarly, testing at the September 2011 VA examination revealed flexion to 60 degrees with pain at the endpoint of motion, and the May 2014 VA examiner found flexion to 90 degrees, with pain beginning at 65 degrees.  As noted above, in VA Fast Letter 06-25, VA has determined that repetitive testing of a joint should yield sufficient information on any functional loss due to an orthopedic disability.  In this case, the Board has taken into consideration the Veteran's complaints of pain on flexion of the lumbar spine at his VA examinations, discussed above, and nevertheless finds that the Veteran's forward flexion of the lumbar spine is functionally limited to, at worst, the 60 degrees recorded at the September 2011 VA examination.  The Board thus concludes that the Veteran's range of motion and functional loss does not warrant a higher rating for his lumbar spine disability.

In that connection, the Board notes that the Veteran has not displayed flexion of the thoracolumbar spine of 30 degrees or less at any time during the appellate period, even when considering pain on motion, to warrant a 40 percent rating.  Similarly, the Board also notes that there is no evidence that the Veteran's degenerative disc disease of the lumbar spine results in disability comparable to ankylosis to warrant a 50 or 100 percent disability rating.  The Board acknowledges that the Veteran's VA examinations revealed painful motion of the lumbar spine.  However, as discussed above, the Board finds that any such pain and its effect on the Veteran's function is contemplated in the 20 percent rating currently assigned.  Therefore, the Board does not find that a rating higher than the 20 percent currently assigned, based on any additional functional loss under 38 C.F.R. §§ 4.40, 4.45, or 4.59, is warranted under the rating criteria.

The Board has also considered the Veteran's degenerative disc disease of the lumbar spine under the rating criteria for intervertebral disc syndrome.  However, the evidence does not support a higher rating.  In that connection, although the Veteran's private physician stated in July 2010 that the Veteran had experienced incapacitating episodes of six weeks' duration over the previous year, the Board notes that no treatment provider or VA examiner has diagnosed the Veteran with intervertebral disc syndrome.  To the contrary, the September 2011 and May 2014 VA examiners specifically found him not to experience intervertebral disc syndrome.  As such, the Board finds that consideration of the Veteran's degenerative disc disease of the lumbar spine under the rating criteria for intervertebral disc syndrome would be inappropriate. 

The Board also finds that there are no other potentially applicable Diagnostic Codes by which to consider the Veteran's service-connected degenerative disc disease of the lumbar spine.  In this case, he is being rated for limitation of motion of the lumbosacral spine.  The Board also notes, as discussed above, that there is no evidence that the Veteran's lumbar spine disorder has resulted in disability comparable to ankylosis at any time during the appeal period, rendering higher ratings under the current General Rating Formula for Diseases and Injuries of the Spine inappropriate.  The Board further finds that no separate ratings are warranted for neurological disorders.  In that connection, the Board notes, as discussed in detail below, that the Veteran has been diagnosed with bilateral lower extremity radiculopathy; the ratings for those disabilities are discussed herein.  Otherwise, no neurological disorder associated with the Veteran's degenerative disc disease of the lumbar spine has been diagnosed at any point during the appeal period.  Thus, the Board finds that no other separate rating for neurological disability is warranted.

The Board acknowledges that the Veteran has complained of painful motion of his lumbar spine.  In this case, as discussed in detail above, the Board has taken into consideration the Veteran's complaints of pain but finds that higher ratings are not warranted for functional loss due to pain.  The Board does not find that ratings higher than the 20 percent currently assigned for the Veteran's lumbar spine disability based on any additional functional loss under 38 C.F.R. §§ 4.40, 4.45, or 4.59 is warranted under the rating criteria.

Regarding the initial ratings assigned to the Veteran's radiculopathy of the right and left lower extremities, after a review of the medical evidence, the Board finds that the Veteran's service-connected radiculopathy of the right lower extremity has resulted in disability approximating no worse than slight incomplete paralysis of the sciatic nerve.  The Board similarly finds that the Veteran's service-connected radiculopathy of the left lower extremity has resulted in disability approximating no worse than slight incomplete paralysis of the femoral nerve.  Because the Veteran is already in receipt of initial 10 percent ratings, which contemplate slight impairment of the right sciatic nerve and the left femoral nerve, higher ratings are not warranted for radiculopathy of the right or left lower extremity.  In that connection, the Board notes that there is no evidence that the Veteran has experienced moderate incomplete paralysis of the right or left lower extremity at any time during the appeal period.  Although he has repeatedly complained of pain, numbness, and tingling radiating into his lower extremities, and in particular his right leg, the May 2014 VA examiner specifically considered these contentions when diagnosing radiculopathy of the right sciatic nerve and left femoral nerve that are mild in severity.  The Board therefore concludes that these disabilities equate to no more than slight incomplete paralysis of the sciatic nerve on the right and slight incomplete paralysis of the femoral nerve on the left, warranting no more than the 10 percent disability ratings initially assigned under Diagnostic Codes 8520 and 8526.  In so finding, the Board looks particularly to the provision of 38 C.F.R. § 4.124a that establishes that when neurological involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree.  38 C.F.R. § 4.124a.

Regarding the effective dates of the grant of service connection for radiculopathy of the right and left lower extremities, the Board notes that the assignment of effective dates for awards of disability compensation is generally governed by 38 U.S.C.A. § 5110 and 38 C.F.R. § 3.400.  As pertinent here, where a claim has not been filed within one year after separation from service, the law provides that the effective date of an award of service-connected disability compensation based on an original claim or a claim reopened after final adjudication "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor."  38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400 (b) (2).

Generally, except as otherwise provided, the effective date of a compensation award based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim, or the date entitlement arose, whichever is later.  38 U.S.C.A. § 5110; 38 C.F.R. § 3.400.  In Roper v. Nicholson, 20 Vet. App. 173 (2006), the Court held that effective dates for both primary and secondary conditions are governed by 38 C.F.R. § 3.400, which provides that the effective date is the later of the date the condition arose or the date the Veteran applied for benefits.

Here, the Veteran seeks an effective date earlier than May 12, 2014, for the grant of service connection (more specifically, separate ratings) for left and right lower extremity radiculopathy.  The Board notes in that connection that service connection was granted based on diagnosis of these disabilities as related to the Veteran's service-connected degenerative disc disease of the lumbar spine.  Upon review of the record, the Board finds that, despite being replete with the Veteran's prior complaints of pain radiating from his lumbar spine into his lower extremities, the record first reflects an objective medical diagnosis of radiculopathy of the right lower extremity on July 21, 2010, when the Veteran was first diagnosed with "right-sided sciatica" associated with his service-connected lumbar spine disability.  Thus, the Board finds that an effective date of July 21, 2010, for service connection for radiculopathy of the right lower extremity is warranted.  However, there is no indication in the record of a diagnosis of left lower extremity radiculopathy until May 12, 2014, when the VA examiner diagnosed mild radiculopathy of the left femoral nerve.  Earlier examinations had not revealed any neurological deficit in the lower extremities attributable to the service-connected low back disability  The Board finds that an effective date of July 21, 2010, but no earlier, is warranted for the grant of service connection for radiculopathy of the right lower extremity, and that entitlement to a separate rating for radiculopathy of the left lower extremity did not arise until May 12, 2014.

In relevant part, 38 U.S.C.A. § 1154(a) (West 2014) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits.  Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (holding that the Board "cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence").  In this case, the Board notes that the Veteran, while entirely competent to report his symptoms both current and past (including radiating pain, numbness and tingling), as a lay person is not competent to associate any of his claimed symptoms to the clinical diagnosis of radiculopathy of the left and right lower extremities.  Such opinion requires specific medical training on the neurological system and is beyond the competency of the Veteran or any other lay person.  In the absence of evidence indicating that the Veteran has the medical training to render neurological opinions, the Board must find that his contention with regard to his right lower extremity radiculopathy prior to July 21, 2010, and with regard to his left lower extremity radiculopathy prior to May 12, 2104, are of no probative value.  See 38 C.F.R. § 3.159(a)(1) (2015) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions).  Accordingly, the statements offered by the Veteran in support of his own claim are not competent evidence of a diagnosis of right lower extremity radiculopathy prior to July 21, 2010, or of a diagnosis of left lower extremity radiculopathy prior to May 12, 2014.

The Board has considered the Veteran's and his representative's contentions with regard to his claims for higher ratings for his service-connected hearing loss, wrist, lumbar spine, and lower extremity disabilities.  Although the Board does not doubt the sincerity of the Veteran's belief that his disabilities are more severely disabling than reflected in the current ratings, as a lay person without the appropriate medical training or expertise, he simply is not competent to provide a probative opinion on a medical matter, such as the severity of a current disability as evaluated in the context of the rating criteria.  See Bostain v. West, 11 Vet. App. 124, 127 (1998).

The above determinations regarding the Veteran's claims for increase are based on consideration of the applicable provisions of VA's rating schedule.  In particular, the Board notes that the March 2012, December 2013, and May 2014 VA audiological examination reports each describe the effects of the Veteran's hearing impairments on his daily life.  See Martinak v. Nicholson, 21 Vet. App. 447 (2007).  The Board also finds that at no time have the disorders under consideration been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis.  See 38 C.F.R. § 3.321(b)(1).  Here, there is an absence of evidence of marked interference with employment (i.e., beyond that contemplated in the assigned evaluation), frequent periods of hospitalization, or evidence that the Veteran's service-connected disabilities as addressed herein have otherwise rendered impractical the application of the regular schedular standards.  The criteria for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) are not met.  See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995).

Furthermore, it bears emphasis that the schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations.  38 U.S.C.A. § 1155.  Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability.  38 C.F.R. § 4.1 (2015).  Though the Veteran reportedly had trouble hearing his students, difficulty hearing is a factor in evaluation the service-connected hearing loss.  The evidence does not demonstrate any unusual disability with respect to the claims decided herein that is not contemplated by the rating schedule.  See Thun v. Peake, 22 Vet. App. 111 (2008).  As a result, the Board concludes that a remand for referral of the rating issues to the VA Central Office for consideration of extra-schedular evaluation is not warranted.

The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a claimant 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 address all the service-connected symptoms.  However, in this case, there is no indication that any symptoms have not been attributed to specific service-connected disabilities, and the Board finds no additional symptoms related to the combination of the Veteran's service-connected disabilities.  Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions.  

In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against these claims, that doctrine is not helpful.  See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990).


ORDER

Entitlement to a disability rating higher than 10 percent for hearing loss is denied.

Entitlement to a disability rating higher than 10 percent for tenosynovitis of the right wrist is denied.

Entitlement to a disability rating higher than 10 percent for tenosynovitis of the left wrist is denied.

Entitlement to a disability rating higher than 20 percent for degenerative disc disease of the lumbar spine is denied.

Entitlement to an initial disability rating in excess of 10 percent for radiculopathy of the right lower extremity is denied.

Entitlement to an initial disability rating in excess of 10 percent for radiculopathy of the left lower extremity is denied.

Entitlement to an effective date of July 21, 2010, for the grant of service connection for radiculopathy of the right lower extremity is granted.

Entitlement to an effective date earlier than May 12, 2014, for the grant of service connection for radiculopathy of the left lower extremity is denied.


REMAND

The Veteran contends that he experiences erectile dysfunction that began while he was in service.  In addition, he has raised the possibility that he developed erectile dysfunction secondary to his service-connected degenerative disc disease of the lumbar spine.

Service treatment records from the Veteran's period of active military service do not reflect any findings or complaints of erectile dysfunction.  Post-service treatment records reflect that the Veteran was first seen in September 2005 for complaints of erectile problems for " a few months"; he was diagnosed at that time with "impotence."  Additionally, the Veteran underwent VA examination in March 2012 concerning his claimed erectile dysfunction.  Report of that examination reflects that the Veteran stated that his erectile dysfunction began in 1990, while he was still on active duty.  The examiner diagnosed erectile dysfunction but opined that it was less likely than not due to his service-connected lumbar spine disability.  In so finding, the examiner stated that "there is no established cause" of erectile dysfunction and noted that there had "never been a workup to determine the etiology" of the Veteran's erectile disorder.  The examiner stated that without such a "workup and with no clear indication that it may or may not be due to the lumbar spine, I cannot determine that it is at least as likely as not secondary to the lumbar spine condition ... In the absence of a workup ruling out other etiologies, I must determine that [erectile dysfunction] is less likely than not due to the lumbar spine condition."  Further, the examiner did not offer an opinion as to whether it is at least as likely as not that the Veteran's erectile dysfunction began or is otherwise etiologically linked to his time on active duty, particularly given his report at the time that the disorder began in 1990, while he was still in service.  

The Court has held that once VA undertakes the effort to provide an examination when developing a claim for service connection, even if not statutorily obligated to do so, it must provide an adequate one.  See Woehlaert v. Nicholson, 21 Vet. App. 456, 464 (2007), citing Barr, 21 Vet. App. at 311; see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence . . . is essential for a proper appellate decision").  However, in this case, there is of record no adequately reasoned opinion as to whether the Veteran currently experiences erectile dysfunction that is directly related to service or that has been caused or worsened by his service-connected lumbar spine disability.  Thus, the VA medical opinions obtained to date are insufficient.  See 38 C.F.R. § 4.2 (2015) (providing that where an examination report does not contain sufficient detail, it is inadequate for evaluation purposes); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that a medical examination report must contain clear conclusions with supporting data and a reasoned medical explanation connecting the two); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions).  

Specifically, the March 2012 VA examiner failed to offer an opinion as to whether the Veteran's erectile dysfunction began in or is otherwise directly linked to his time on active duty, particularly given his contentions concerning its onset in 1990.  The examiner further failed to provide any discussion of his finding that the disorder is less likely than not related to the Veteran's lumbar spine disability other than decrying the lack of a "workup" to assess the disorder's likely etiology.  In addition, the examiner failed to provide any opinion as to whether the Veteran's erectile dysfunction has been aggravated by his lumbar spine disability.  The Board thus finds that a more complete examination, including a "workup" to assess the etiology of the erectile dysfunction, and additional medical opinion from a VA examiner is needed regarding the Veteran's claim for erectile dysfunction.  The examiner must conduct thorough examination of the Veteran, including any "workup" necessary to determine the etiology of his diagnosed erectile dysfunction.  The examiner must specifically address whether his erectile dysfunction began in or is directly related to his time on active duty or has been caused or aggravated by his service-connected degenerative disc disease of the lumbar spine.  The examiner must specifically discuss the Veteran's contentions that his erectile dysfunction began during service, as well as his September 2005 report of erectile problems for " a few months," in the context of any opinion.  See 38 U.S.C.A. § 5103A. 

Additionally, in a December 2014 rating decision, the RO granted service connection for umbilical hernia and inguinal hernia, assigning initial noncompensable disability ratings for both disabilities, and denied his petition to reopen a previously denied claim for service connection for plantar fasciitis of the right foot, finding that no new and material evidence had been submitted.  Also in that decision, the RO denied the Veteran's claim for service connection for flat feet.  In a February 2015 rating decision, the RO granted service connection for folliculitis with eczema, assigning an initial 10 percent rating effective from May 8, 2008.  In March 2015 and May 2015, the Veteran submitted correspondence expressing disagreement with the initial ratings and effective dates awarded for the grants of service connection, as well as with the denial of the petition to reopen the claim of service connection for plantar fasciitis of the right foot and service connection for flat feet.  These matters must be returned to the AOJ for appropriate consideration and issuance of a statement of the case with regard to such issues.  Manlincon v. West, 12, Vet. App. 238 (1999).

Accordingly, the case is REMANDED for the following action:

1.  The Veteran must be scheduled for VA examination to determine the etiology of his diagnosed erectile dysfunction.  Such examination must include any "workup" deemed necessary, such as that referenced by the March 2012 VA examiner.  The examiner must 

provide an opinion as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that the Veteran's erectile dysfunction is attributable to his time on active duty.  The Veteran's report that he first experienced erectile problems in 1990 while in service, as well as his conflicting report in September 2005 of erectile problems for "a few months," must be discussed in the context of any negative opinion.

The examiner must also provide a well-reasoned opinion as to whether it is at least as likely as not that the Veteran's erectile dysfunction has been caused or made chronically worse by his service-connected lumbar spine disability.  If aggravated, specify the baseline of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation.  

The examiner must thoroughly review the Veteran's claims file, to include a copy of this remand.  A well-reasoned opinion must be provided with a detailed explanation for all conclusions reached by the reviewer.  Citations to the record or relevant medical principles should be included as necessary to explain the opinion, and a complete rationale must be given for all opinions and conclusions expressed.

2.  After completing the requested actions and any additional notification and/or development deemed warranted, the claim remaining on appeal must be adjudicated in light of all pertinent evidence and legal authority.  If any benefit sought is not granted, the Veteran must be furnished a supplemental statement of the case and afforded the appropriate time period for response before the claims file is returned to the Board.

3.  Appropriate action should be taken pursuant to 38 C.F.R. § 19.26 in response to the March 2015 and May 2015 notices of disagreement, including issuance of an appropriate statement of the case, pertaining to the issues of whether new and material evidence has been received to reopen a claim for service connection for plantar fasciitis of the right foot; entitlement to service connection for flat feet; entitlement to an initial disability rating in excess of 10 percent for folliculitis with eczema; entitlement to an effective date earlier than May 8, 2008, for the grant of service connection for folliculitis with eczema; and entitlement to initial compensable disability ratings for umbilical hernia and inguinal hernia, so that the Veteran may have the opportunity to complete the appeal by filing a timely substantive appeal.

The appellant has the right to submit additional evidence and argument on the matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West 2014).



______________________________________________
THOMAS J. DANNAHER
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs