Citation Nr: 1646246 Decision Date: 12/09/16 Archive Date: 12/21/16 DOCKET NO. 11-01 217 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an increased rating in excess of 10 percent for service-connected heart murmur with mitral valve prolapse. 2. Entitlement to an increased rating in excess of 10 percent for service-connected hypertension. 3. Entitlement to an increased rating in excess of 10 percent for service-connected tinnitus. 4. Entitlement to an initial rating in excess of 10 percent for service-connected hypertensive retinopathy. 5. Entitlement to a compensable initial rating for service-connected nephrolithiasis. 6. Entitlement to an increased rating in excess of 10 percent for service-connected patellofemoral syndrome of the right knee. 7. Entitlement to an increased rating in excess of 10 percent for service-connected degenerative disc disease (DDD) of the lumbosacral spine. 8. Entitlement to service connection for a right hip disability. REPRESENTATION Veteran represented by: Lawrence W. Stokes, Jr., Agent ATTORNEY FOR THE BOARD K. K. Buckley, Counsel INTRODUCTION The Veteran served on active duty from July 1976 to July 1996. Service in Southwest Asia is indicated by the record. He is the recipient of the Combat Infantry Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The October 2008 rating decision granted entitlement to service connection for hypertensive retinopathy and assigned a noncompensable (zero percent) rating. The decision also granted entitlement to service connection for nephrolithiasis and assigned a noncompensable (zero percent) evaluation. In addition, the rating decision denied increased ratings as to heart murmur with mitral valve prolapse, hypertension, right knee patellofemoral syndrome, DDD of the lumbosacral spine, and tinnitus; as well as entitlement to service connection for a right hip disability. In a May 2016 rating decision, the RO granted an increased 10 percent rating for the service-connected hypertensive retinopathy. The Veteran has not expressed satisfaction with the increased initial disability rating; this issue thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). The issues of entitlement to increased ratings for disabilities of the right knee and lumbar spine, as well as entitlement to service connection for a right hip disability are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). The Veteran will be notified if further action on his part is required. FINDINGS OF FACT 1. The Veteran's service-connected heart murmur with mitral valve prolapse more nearly approximates a workload of greater than 5 METS level but less than 7 METS with dyspnea and fatigue, a left ventricular ejection fraction in excess of 50 percent, and no evidence of acute or chronic congestive heart failure. 2. The Veteran's service-connected hypertension requires the regular use of prescribed medications with a history of increased blood pressure readings; symptoms have not more nearly approximated predominant diastolic blood pressure of 110 or more, or a predominant systolic blood pressure of 200 or more. 3. The Veteran's service-connected bilateral tinnitus is assigned the maximum rating authorized under Diagnostic Code 6260. 4. The Veteran's service-connected hypertensive retinopathy manifests in impairment of field of vision with an average contraction of 50 in the left eye and 54.375 in the right eye. Best corrected far visual acuity in the right and left eyes is 20/40. Corrected near visual acuity is 20/40 in each eye. 5. The Veteran's service-connected nephrolithiasis is largely asymptomatic and is not manifested by an occasional attack of colic without infection and without requiring catheter drainage. 6. The evidence does not show that the Veteran's service-connected disabilities are so exceptional or unusual that referral for extraschedular consideration is warranted; the criteria contemplate the symptoms and the disabilities do not individually or collective cause marked interference with employment or frequent hospitalization. CONCLUSIONS OF LAW 1. A disability rating of 30 percent, but no higher, is warranted for the Veteran's heart murmur with mitral valve prolapse. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.104, Diagnostic Code 7000 (2015). 2. The criteria for a disability rating in excess of 10 percent for service-connected hypertension have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2015). 3. There is no legal basis for a schedular rating in excess of 10 percent for the Veteran's tinnitus. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.87, Diagnostic Code 6260 (2015). 4. An initial rating of 20 percent, but no higher, is warranted for the Veteran's hypertensive retinopathy. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.75, 4.79 (2015), 4.84a, Diagnostic Codes 6006, 6066 (2008). 5. The criteria for an initial compensable disability rating for nephrolithiasis have not been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.14, 4.115a, 4.115b, Diagnostic Code 7508 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA); Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). The VCAA requires VA to notify a claimant of the information and evidence needed to substantiate a claim, and assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Pre-decisional notice letters dated in January 2008 and May 2008 complied with VA's duty to notify the Veteran including as to the increased and initial rating claims. As to the hypertensive retinopathy and nephrolithiasis, when service connection has been granted and the initial rating and effective date has been assigned, the claim of service connection has been more than substantiated. Once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional § 5103(a) notice. See Dingess v. Nicholson, 19 Vet. App. 473,490-491 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Moreover, the January 2008 and May 2008 letters informed the Veteran that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Accordingly, the duty to notify is satisfied. With respect to VA's duty to assist, the Veteran's service treatment records (STRs), as well as VA and private treatment records have been obtained and associated with the claims file. The Veteran was also afforded pertinent VA examinations in June 2008, April 2013, September 2014, October 2015, and February 2016. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). For the reasons indicated below, the VA examinations conducted are collectively sufficient, as the examiners considered all of the pertinent evidence of record, including the statements of the Veteran, and provided explanations for the opinions stated, as well as the medical information necessary to apply the appropriate rating criteria. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the pending claims has been met. 38 C.F.R. § 3.159(c)(4). II. Schedular analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. a. Heart murmur with mitral valve prolapse In general, when 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). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's heart murmur with mitral valve prolapse is rated as valvular heart disease under Diagnostic Codes 7099-7000. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. When an unlisted disease or injury is encountered, it will be rated by analogy under a diagnostic code built up using the first 2 digits from that part of the Rating Schedule most closely identifying the body part or system affected and by using "99" for the last 2 digits. Id. Under Diagnostic Code (DC) 7000, during active infection with valvular heart damage and for three months following cessation of therapy for the active infection, a 100 percent rating is warranted. Thereafter, with valvular heart disease (documented by findings on physical examination and either echocardiogram, Doppler echocardiogram, or cardiac catheterization) resulting in: * Chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent warrants a 100 percent rating. * More than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent warrants a 60 percent rating. * Workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electro-cardiogram, echocardiogram, or X-ray warrants a 30 percent rating. * Workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required warrants a 10 percent rating. One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. In this matter, the Veteran contends that he is entitled to an increased disability rating throughout the appeal period. See, e.g., the Veteran's VA Form 9 dated January 2011. For the reasons set forth below, the Board finds that a rating of 30 percent, but no higher, is warranted. A February 2006 VA treatment records noted that a baseline electrocardiogram (EKG) revealed bradycardia. A June 2008 VA examination documented the Veteran's report of fatigue, at which time his pulse was regular at 60 beats per minute. His heart sounds were normal at S1 and S2 without evidence of clicks, rubs, or murmurs. There was no evidence of jugular venous distension. A December 2007 chest x-ray showed, "[n]o evidence of acute cardiopulmonary process; specifically, no evidence of adenopathy or infiltrate." An April 2013 VA examination noted that the Veteran was well developed, well nourished, and in no acute distress. Heart sounds were normal at S1 and S2, and there was no evidence of S3 and S4. There was normal rate and regular rhythm. There was no evidence of murmurs, gallops, heaves, or thrills. The examiner also reported that the Veteran did not exhibit clubbing or cyanosis. The Veteran was afforded a VA examination in February 2016 as to his heart murmur with mitral valve prolapse. He reported that the condition had worsened since his last examination. He stated, "I find myself breathing harder, some pain in [my] chest [and] wheezing." Continuous medication is not required for the Veteran's heart murmur with mitral valve prolapse. There was no evidence of myocardial infarction or congestive heart failure. The Veteran has intermittent (paroxysmal) atrial flutter; specifically, one to four episodes in the past twelve months as documented by EKG. There was no supraventricular tachycardia, heart valve condition, infectious cardiac condition, or pericardial adhesion. The Veteran has not had any surgical procedures for his heart murmur with mitral valve prolapse; he also had no hospitalizations. Upon physical examination, the Veteran's heart rhythm was regular. Heart sounds were normal. There was no jugular venous distension. A February 2016 EKG showed "normal sinus rhythm, nonspecific T-wave abnormality." A February 2016 echocardiogram showed left ventricular ejection fraction at 67 percent with normal wall motion and thickness. A February 2016 chest x-ray was normal. The examiner performed interview-based METS testing, and estimated the Veteran's METs workload at between 7 and 10. The Veteran experienced dyspnea and fatigue. However, the examiner noted that this METs level was not due solely to the claimed heart condition; rather, the examiner reported that the Veteran's estimated METs workload due solely to the cardiac condition was between 5 to 7. The examiner indicated that the Veteran's heart murmur with mitral valve prolapse does not impact his ability to work. He further stated, "[a]t this time, the claimant's condition is asymptomatic." In this case, the evidence shows that the Veteran's service-connected heart murmur with mitral valve prolapse is manifested by a workload of greater than 5 METs but symptoms did not more nearly approximate greater than 7 METs resulting in dyspnea and fatigue. As such, the Board finds that a 30 percent evaluation, but no higher, is warranted under DC 7000. The Board has considered whether a rating in excess of 30 percent is warranted. However, the Veteran's workload resulting in dyspnea and fatigue has not been less than 5 METs. Left ventricular ejection fraction has consistently been greater than 50 percent, and the Veteran has history of congestive heart failure. Therefore, the criteria for a rating greater than 30 percent under DC 7000 have not been met. The Board has also considered the applicability of other diagnostic codes for rating the Veteran's disability, but finds that no other diagnostic code provides a basis for higher rating. DC 7000 specifically pertains to valvular heart disease, and the Veteran's disability has not been shown to involve any factors that warrant evaluation under any other provision of VA's rating schedule. Accordingly, a rating of 30 percent, but no higher, is warranted for the Veteran's service-connected heart murmur with mitral valve prolapse under the schedular criteria. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107 (b). b. Hypertension In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco, 7 Vet. App. at 58. However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart, supra. The analysis in this decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's hypertension has been assigned a noncompensable evaluation under 38 C.F.R. § 4.104, DC 7101. Under that DC, a 10 percent evaluation is warranted where diastolic blood pressure is predominantly 100 or more, or systolic blood pressure is predominantly 160 or more, or when an individual with a history of diastolic blood pressure predominantly 100 or more requires continuous medication for control. A 20 percent evaluation is warranted where diastolic blood pressure is predominantly 110 or more, or systolic blood pressure is predominantly 200 or more. A 40 percent evaluation is warranted where diastolic pressure is predominantly 120 or more, and a 60 percent evaluation is warranted where diastolic blood pressure is predominantly 130 or more. 38 C.F.R. § 4.104. In his October 2007 claim, the Veteran asserted that he is entitled to an increased disability rating for hypertension. See, e.g., the VA Form 9 dated January 2011. As described above, the Veteran's service-connected hypertension was assigned a 10 percent evaluation under DC 7101. The Board finds that an increased disability rating is not warranted for this period. The Veteran was afforded a VA examination in June 2008 at which time he reported that his hypertension had progressively worsened since onset. He is on continuous medication to manage his hypertension. He has not had any hospitalizations or surgery as a result of his hypertension. He reported fatigue. Blood pressure readings at examination were 124/77, 116/69, and 118/68. There was no evidence of hypertensive heart disease. The examiner noted that the Veteran's hypertension is well-controlled, and has no significant occupational effects. Also, the hypertension has no effect on the Veteran's daily activities. VA treatment records dated in June 2011 document blood pressure readings of 139/80, 142/88, and 116/85. A reading of 122/85 in July 2011, and a reading of 106/72 was noted in September 2011. From 2012 through 2015, the following readings were documented in VA treatment records: 109/68 (January 2012), 112/76 (May 2012), 132/76 (February 2013), 132/76 (March 2013), 104/66 (April 2013), 114/78 (February 2014), 101/65 (April 2014), 108/67 (February 2015), 132/80 and 114/69 (March 2015), 122/75 and 117/73 (June 2015), 110/73 and 125/80 (July 2015), 115/74 and 174/81 (August 2015), 134/81 (October 2015), 133/73 and 125/77 (November 2015), and 128/76 (December 2015). The Veteran was afforded a VA examination in February 2016 at which time the examiner confirmed that the Veteran's hypertension is well-controlled on continuous medication. Blood pressure readings were 135/84, 140/81, and 135/77. The Veteran does not have a history of diastolic blood pressure elevation to predominantly 100 or more. His hypertension has no impact on his ability to work. VA treatment records dated in 2016 showed the following blood pressure readings: 128/81 (January 2016), 138/84 (February 2016), 146/82 and 138/84 (March 2016), 176/80, 137/88, and 143/87 (April 2016). The evidence of record does not demonstrate any findings of diastolic pressure of 110 or more, or systolic pressure of 200 or more; as such, the criteria for a 20 percent, or higher, evaluation are not met at any time during the appeal period. Thus, for the reasons stated above, the criteria for a disability rating in excess of 10 percent for the Veteran's service-connected hypertension have not been met or approximated. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b). c. Tinnitus Tinnitus is evaluated under DC 6260, which was revised effective June 13, 2003, to clarify existing VA practice that only a single 10 percent evaluation is assigned for tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, DC 6260, note 2 (2015). This is the maximum schedular evaluation assignable for that condition. The Federal Circuit affirmed VA's long-standing interpretation of DC 6260 as authorizing only a single 10 percent rating for tinnitus, whether perceived as unilateral or bilateral. Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). Citing Supreme Court precedent, the Federal Circuit explained that an agency's interpretation of its own regulations was entitled to substantial deference by the courts as long as that interpretation was not plainly erroneous or inconsistent with the regulations. Id. at 1349-50. The Veteran's service-connected tinnitus has been assigned the maximum schedular rating available for tinnitus under 38 C.F.R. §4.87, DC 6260, and there is no legal basis upon which to award more than a single 10 percent rating. In light of the above, the Veteran's appeal as to this claim must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). d. Hypertensive retinopathy When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart, supra. Here, the Veteran was assigned a 10 percent evaluation for his hypertensive retinopathy from October 15, 2007, the date of his service connection claim. The Veteran's service-connected hypertensive retinopathy is rated under DC 6006-6066. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. In this case, the hyphenated diagnostic code indicates that retinopathy, under DC 6006, is the service-connected disability and impairment of visual acuity, under DC 6066, is a residual condition. The Board notes that, during the course of this appeal, VA revised the criteria for rating eye disabilities, effective December 10, 2008. 73 Fed. Reg. 66,543 (2008) (codified at 38 C.F.R. §§ 4.75-4.79). The new regulations are effective only as to claims filed on or after December 10, 2008. As this claim was filed prior to that date, the regulations in effect before December 2008 revision will apply. Prior to December 10, 2008, chronic diseases of the eye listed at Diagnostic Codes 6000 through 6009 were rated from 10 percent to 100 percent for impairment of visual acuity or field loss, pain, rest-requirements, or episodic incapacity, combining an additional rating of 10 percent during continuance of active pathology. A minimum rating of 10 percent was to be assigned during active pathology. 38 C.F.R. § 4.84a, DCs 6000-6009 (2008). Pursuant to the prior rating criteria, central visual acuity was evaluated based on the degree of the resulting impairment of visual acuity, based on the best distant vision obtainable after the best correction by glasses. 38 C.F.R. §§ 4.75, 4.84a, DCs 6061-6079 (2008). The percentage evaluation was found on Table V of the old rating criteria by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a. Pursuant to the prior rating criteria, impairment of field of vision was assigned a disability rating based on the extent of the contraction of the visual field in each eye, which was determined by recording the extent of the remaining visual fields in each of the eight 45 degree principal meridians. The number of degrees lost was determined at each meridian by subtracting the remaining degrees from the normal visual fields given in Table III. The degrees lost were then added together to determine total degrees lost, which was subtracted from 500. The difference, which represented the total remaining degrees of visual field, was divided by eight to determine the average contraction for rating purposes. 38 C.F.R. § 4.76a, Table III. A 10 percent disability rating was assigned for unilateral loss of the nasal or temporal half of the visual field; or unilateral concentric contraction of the visual field between 16 and 60 degrees. Id. A 20 percent disability rating was assigned for bilateral loss of the nasal half of the visual field; unilateral concentric contraction of the visual field between 6 and 15 degrees; or bilateral concentric contraction of the visual field between 46 and 60 degrees. Id. A 30 percent disability rating is assigned for homonymous hemianopsia; bilateral loss of the temporal half of the visual field; unilateral concentric contraction of the visual field to 5 degrees; or bilateral concentric contraction of the visual field between 31 and 45 degrees. Id. A 50 percent disability rating is assigned for bilateral concentric contraction of the visual field between 16 and 30 degrees. Id. A 70 percent disability rating is assigned for bilateral concentric contraction of the visual field between 6 and 15 degrees. A maximum 100 percent disability rating is assigned for bilateral concentric contraction of the visual field to 5 degrees. Id. According to Table III in 38 C.F.R. § 4.76a, the normal visual field extent at the 8 principal meridians, in degrees, is: temporally, 85; down temporally, 85; down, 65; down nasally, 50; nasally, 60; up nasally, 55; up, 45; up temporally, 55. The total visual field is 500 degrees. 38 C.F.R. § 4.76a, Table III (2008). In this matter, the Board has reviewed the record and, for the reasons stated below, finds a that a rating of 20 percent, but no higher, is warranted from the date of service connection. A December 2007 private treatment record noted presbyopia. A June 2008 private ophthalmology note documented diagnoses of possible idiopathic juxtafoveal retinal telangiectasia (IJRT) in the right eye, as well as a small foveal cyst in the right eye, and a small choroidal osteoma in the left eye. The Veteran was granted service connection for hypertensive retinopathy in an October 2008 rating decision, based on medical evidence in-lieu of a VA examination due to his inability to appear for an examination at the time. A March 2009 treatment record noted the Veteran's report of experiencing sharp pain in his right eye for approximately three weeks. He stated that his vision becomes blurry five to six times per week, and was slightly blurry at the time of the examination. In September 2012, the Veteran complained of a "paper cut feeling" in the right eye. In March 2013, he reported, "I still have that cutting sensation in my right eye. I've used artificial tears, the lubricant, the warm compresses, and the lid scrubs, but none of that works." He was diagnosed with macular edema secondary to IJRT in the right eye, "causing significant decrease in vision today." It was also noted that the Veteran's "choroidal osteoma of the posterior pole" of the left eye was stable upon examination. The Veteran was afforded a VA examination in February 2016 at which time a diagnosis of hypertensive retinopathy was confirmed. He was also diagnosed with preoperative cataracts and a chorioretinal scar. The examiner indicated that the Veteran's hypertensive retinopathy had remained the same. His best corrected near vision was 20/40 or better in both eyes. His best corrected far vision was 20/40 or better in both eyes. His pupils were round and reactive to light. There was no afferent pupillary defect present. There was no diplopia. An internal eye examination revealed a macular scar in the right eye with vessels attenuated in both eyes. There was a visual field defect, but no loss of visual field, no contraction of visual field, and no scotoma. There was no aphakia or dislocation of the crystalline lens. The Veteran did not have any incapacitating episodes due to his hypertensive retinopathy. The examiner noted, "[t]here is no decrease in visual acuity or other visual impairment." The retinopathy was present in both eyes. The examiner noted that the bilateral cataracts and chorioretinal scar in the right eye were new and separate diagnoses. The February 2016 VA examination report also showed average contraction of the field of vision of the left eye to 50 degrees. The examination showed a visual field to 60 degrees; a normal field of vision temporally is 85 degrees. Normal vision down temporally is 85; the Veteran's was 60 in the left eye. The normal field of vision down is 65; 55 degrees was shown on examination. Down nasally, 50 is normal; the Veteran had 45. Normal vision nasally is 60; examination findings show 40. Up nasally, 55 is considered normal; 40 was demonstrated. The normal field of vision up is 45 degrees; 45 was shown. The final field of vision considered for the left eye is up temporally. 55 is normal with 55 shown on examination. As such, the total remaining visual field for the left eye is 400. When this number is divided by the eight directions, rounded up, the average contraction of 50 degrees is obtained. The February 2016 VA examination showed the Veteran's average right eye contraction to 54.375 degrees. This is based on the following examination findings: a normal field of vision temporally is 85 degrees; examination shows 60 degrees. Normal vision down temporally is 85; the Veteran's was 80 in the right eye. Normal field of vision down is 65; the Veteran's was 60 degrees. Down nasally, 50 is normal; 50 degrees was shown. Normal vision nasally is 60; examination findings showed 50. Up nasally, 55 is considered normal; 45 was demonstrated. The normal field of vision up is 45 degrees; 45 was shown. The final field of vision considered for the right eye is up temporally; 55 is normal with 45 shown on examination. Thus, the total remaining visual field for the right eye is 435. When this number is divided by the eight directions, rounded up, the average contraction of 54.375 is obtained. Under the prior version of 6006, a 20 percent disability rating was assigned for bilateral loss of the nasal half of the visual field; unilateral concentric contraction of the visual field between 6 and 15 degrees; or bilateral concentric contraction of the visual field between 46 and 60 degrees. In this matter, the Veteran's bilateral concentric contraction of the visual field is between 45 - 60 degrees (50 in the left eye and 54.375 in the right eye). As such, a 20 percent evaluation is warranted for the hypertensive retinopathy under the pertinent diagnostic criteria. The Board has considered whether a higher evaluation is more nearly approximated. However, the evidence does not support a finding that there is homonymous hemianopsia; bilateral loss of the temporal half of the visual field; unilateral concentric contraction of the visual field to 5 degrees; or bilateral concentric contraction of the visual field between 31 and 45 degrees. Moreover, the Veteran has denied experiencing incapacitating episodes and his corrected vision is 20/40 or better in both eyes. As such, a rating in excess of 20 percent is not warranted. See 38 C.F.R. § 4.79, DC 6006-6066. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b). e. Nephrolithiasis The Veteran was granted service connection for nephrolithiasis (kidney stones) by an October 2008 rating decision where a noncompensable disability rating was assigned, effective October 15, 2007. The Veteran's service-connected nephrolithiasis is rated under 38 C.F.R. § 4.115b, DC 7508. Under DC 7508, nephrolithiasis is rated as hydronephrosis except when there are recurring stone formations that require one or more of the following: diet therapy, drug therapy, and/or invasive or non-invasive procedures more than 2 times a year; in which case a 30 percent evaluation will be assigned. 38 C.F.R. § 4.115b, DC 7508. Otherwise, nephrolithiasis is rated as hydronephrosis. Id. Hydronephrosis is rated as 10 percent rating disabling when there is only an occasional attack of colic, not infected and not requiring catheter drainage. A 20 percent rating is warranted when there are frequent attacks of colic, requiring catheter drainage. A maximum 30 percent evaluation is warranted when there are frequent attacks of colic with infection (pyonephrosis), with impaired kidney function. If hydronephrosis is severe, it is rated as renal dysfunction. 38 C.F.R. § 4.115b, DC 7509. A VA examination conducted in June 2008 noted that the Veteran had blood in his urine. He had normal creatine, BUN, and EGFR; therefore no kidney problems were shown. A March 2013 VA treatment record noted the Veteran's microscopic hematuria with negative imaging and endoscopic evaluation. The Veteran was afforded a VA examination as to his nephrolithiasis in April 2013, at which time he reported that the condition began when he passed kidney stones, but has since improved. He has no current kidney stones and is not on any medication to treat the nephrolithiasis. The examiner reported that there was no evidence of renal dysfunction. There were kidney calculi. There was no treatment for recurrent stone formation in the kidney, ureter, or bladder. There were no signs of symptoms due to urolithiais. There was no history of recurrent symptomatic urinary tract or kidney infections. The examiner reported that the "Veteran gives history of bladder cystoscopy and present with 2+ for blood in urine, which did not show stones, and is not related to this claim." The nephrolithiasis had no impact on the Veteran's ability to work. The examiner indicated that the Veteran's nephrolithiasis is asymptomatic. A July 2015 VA treatment record indicated that the Veteran was feeling lightheaded. It was further indicated that he was "noted to have hematuria and renal insufficiency." An April 2016 VA treatment record documented the Veteran's "history of microscopic blood in urine, difficulty urinating at times, no burning in urination, no frequency, no flank pain, no penile discharge." Overall, an initial compensable evaluation is not warranted for the Veteran's nephrolithiasis. His nephrolithiasis symptomatology does not more nearly approximate the criteria for an increased initial rating under the pertinent diagnostic criteria. Critically, the Veteran does not current suffer from kidney stones. He has not experienced any colic and has not required the use of a catheter. Moreover, there is no evidence of recurrent kidney formation. The Veteran does not require drug or diet therapy, and has not had any procedures to address his kidney stones since the date of service connection. 38 C.F.R. § 4.115b, DCs 7508, 7509. The Board recognizes that renal insufficiency was noted in a July 2015 VA treatment record; however, this notation by itself did not indicate that there was renal impairment warranting a higher or separate rating. Moreover, the Veteran has not suggested, nor does the evidence show, that he has renal insufficiency as a result of his nephrolithiasis. In sum, the evidence is not in relative equipoise. Thus, the preponderance of the evidence is against the claim, and the Veteran's claim of entitlement to a compensable initial evaluation for service-connected nephrolithiasis must be denied. 38 U.S.C.A § 5107 (b). III. Additional considerations Additionally, the Board finds that the Veteran's heart murmur with mitral valve prolapse, hypertension, tinnitus, hypertensive retinopathy, and nephrolithiasis do not warrant referral for extraschedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extraschedular disability rating is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extraschedular disability rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability and the established criteria found in the rating schedule to determine whether a veteran's disability picture is adequately contemplated by the rating schedule. Id. If the disability picture is not adequately contemplated by the rating schedule, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for dermatitis are inadequate. A comparison between the level of severity and symptomatology of the Veteran's heart murmur with mitral valve prolapse, hypertension, tinnitus, hypertensive retinopathy, and nephrolithiasis with the established criteria shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology. Specifically, as described above, the Veteran's heart murmur with mitral valve prolapse manifested as a workload of between 5 to 7 METs with dyspnea and fatigue; these symptoms are contemplated in the assigned schedular rating under DC 7000. His hypertension requires continuous medication, which is contemplated by the schedular rating under DC 7101. The Veteran's constant bilateral tinnitus is specifically contemplated by the assigned schedular rating under DC 6260. Similarly, his hypertensive retinopathy results in a bilateral contracted field of vision, which is contemplated by DC 6066. Lastly, the Veteran's nephrolithiasis manifested as kidney stones in the past with no current treatment, this is contemplated under DC 7508. As such, the Board finds that the Veteran's schedular ratings are adequate to compensate him for his heart murmur with mitral valve prolapse, hypertension, tinnitus, hypertensive retinopathy, and nephrolithiasis, and referral for extraschedular consideration is not warranted. In Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014), the Federal Circuit held that "[t]he plain language of § 3.321(b)(1) provides for referral for extra-schedular consideration based on the collective impact of multiple disabilities." Here, however, the issue has not been argued by the Veteran or reasonably raised by the evidence of record. The Veteran has not asserted, and the evidence of record does not suggest, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. Yancy v. McDonald, 27 Vet. App. 484, 495 (Fed. Cir. 2016) ("the Board is required to address whether referral for extraschedular consideration is warranted for a veteran's disabilities on a collective basis only when that issue is argued by the claimant or reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities"). The Board will therefore not address the issue further. In addition, the Board notes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for a higher rating is whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, neither the Veteran, nor his agent, has suggested that his heart murmur with mitral valve prolapse, hypertension, tinnitus, hypertensive retinopathy, and nephrolithiasis preclude his employment. Additionally, there is no indication in the record that the Veteran's service-connected heart murmur with mitral valve prolapse, hypertension, tinnitus, hypertensive retinopathy, and nephrolithiasis have negatively impacted his employability. Thus, any further consideration of the Veteran's claims under Rice is not warranted at this time. ORDER Entitlement to a rating of 30 percent, but no higher, for heart murmur with mitral valve prolapse is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a rating in excess of 10 percent for hypertension is denied. Entitlement to a rating in excess of 10 percent for bilateral tinnitus is denied. Entitlement to an initial rating of 20 percent, but no higher, for hypertensive retinopathy is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a compensable initial rating for nephrolithiasis is denied. REMAND After having considered the matter, and for reasons expressed immediately below, the Board finds that the remaining issues--entitlement to an increased rating for service-connected lumbosacral strain, entitlement to an increased rating for patellofemoral syndrome of the right knee, and entitlement to service connection for a right hip disability--must be remanded for further development. Since the Veteran's right knee and lumbar spine claims were last before the Board, the United States Court of Appeals for Veterans Claims (Court) issued a decision in Correia v. McDonald, 28 Vet. App. 158 (2016). In that decision, the Court held that the final sentence of 38 C.F.R. § 4.59 requires that VA musculoskeletal examinations include joint testing for pain on both active and passive motion, and in weight-bearing and nonweight-bearing (and, if possible, with range of motion measurements of the opposite undamaged joint). Critically, this type of joint testing was not accomplished during the Veteran's most recent VA examinations February 2016 and June 2008; accordingly, further VA examination is warranted. Hence, the AOJ should arrange for the Veteran to undergo VA knee and lumbar spine examinations by appropriate medical professionals. See VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination); & Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). The examinations conducted pursuant to this remand should include a review of the Veteran's claims file and past clinical history, with particular attention to the current severity of the symptoms associated with the service-connected right knee and lumbar spine disabilities. With respect to the claim of entitlement to service connection for a right hip disability, the record shows that the Veteran was diagnosed with bursitis of the right hip in December 2007. Moreover, he has asserted that he began to experience right hip pain during his military service. See, e.g., the Veteran's claim dated October 2007. To this end, the Board notes that an October 1994 service treatment record documented the Veteran's report of pain from hip to knee; it was unclear to which hip he was referring. Critically, the Veteran has not been afforded a VA examination as to the right hip disability claim. See Charles v. Principi, 16 Vet. App. 270 (2002); see also 38 C.F.R. § 3.159(c)(4) (2015) (a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim). As such, the matter should be remanded in order for the Veteran to be provided a pertinent VA opinion as to the etiology of the claimed right hip disability. Prior to arranging for the Veteran to undergo further VA examination, to ensure that all due process requirements are met, and that the record is complete, the AOJ should undertake appropriate action to obtain all pertinent, outstanding records. Accordingly, the claims remaining on appeal are REMANDED for the following action: 1. After obtaining the appropriate releases where necessary, procure any records of outstanding treatment and/or evaluation that the Veteran has received, to include any records of VA treatment dating from May 2016. All such available documents must be associated with the claims file. 2. Thereafter, the Veteran should be afforded a VA examination in order to determine the extent of his service-connected lumbar spine disability. The examination should be conducted in accordance with the current disability benefits questionnaire, to include testing for pain on both active and passive motion, and in weight bearing and nonweight-bearing, consistent with 38 C.F.R. § 4.59 as interpreted in Correia v. McDonald, 28 Vet. App. 158 (2016). 3. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo a VA examination as to his right knee by an appropriate medical professional. The examination should be conducted in accordance with the current disability benefits questionnaire, to include testing for pain on both active and passive motion, in weight bearing and nonweight-bearing, and, if possible, with the range of the opposite undamaged joint, consistent with 38 C.F.R. § 4.59 as interpreted in Correia v. McDonald, 28 Vet. App. 158 (2016). 4. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed right hip disability. All indicated tests and studies should be conducted. The claims file, to include a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was accomplished. The examiner is requested to answer the following: Is it at least as likely as not (50 percent probability or more) that any current right hip disability, i.e., approximately since the Veteran filed his claim for service connection in October 2007 had its onset in service or is otherwise related to the Veteran's active duty service? The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports should be specifically acknowledged and considered in formulating opinions. The absence of evidence of treatment for the claimed disorders, in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. Reasons should be provided for any opinion rendered. 5. Thereafter, adjudicate the claims remaining on appeal. If any benefit sought remains denied, the Veteran and his agent should be provided a supplemental statement of the case and given an 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 or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs