Citation Nr: 1648178 Decision Date: 12/27/16 Archive Date: 01/06/17 DOCKET NO. 12-07 870 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and depression. 2. Entitlement to service connection for a back disorder. 3. Entitlement to service connection for a neck disorder. 4. Entitlement to service connection for a right knee disorder. 5. Entitlement to service connection for a left knee disorder. 6. Entitlement to service connection for a right hip disorder. 7. Entitlement to service connection for a left hip disorder. 8. Entitlement to service connection for a nerve disorder of the upper extremities. 9. Entitlement to service connection for a nerve disorder of the lower extremities. 10. Entitlement to service connection for a disability manifested by sleep pattern changes. 11. Entitlement to service connection for a disability manifested by fatigue. 12. Entitlement to an increased initial rating for bilateral hearing loss, rated as noncompensable prior to December 3, 2013, and 10 percent disabling thereafter. 13. Entitlement to an initial rating in excess of 10 percent for tinnitus. ATTORNEY FOR THE BOARD C. Boyd Iwanowski, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1955 to December 1957. These matters come before the Board of Veterans' Appeals (Board) on appeal from May 2010 and March 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan. The claims were remanded by the Board in May 2016; they are now returned to the Board for further adjudication. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. The Veteran does not currently have a diagnosed psychiatric disorder. 2. A chronic back disability was not incurred in service and did not manifest within one year of separation from service. 3. A chronic neck disability was not incurred in service and did not manifest within one year of separation from service. 4. A chronic right knee disability was not incurred in service and did not manifest within one year of separation from service. 5. A chronic left knee disability was not incurred in service and did not manifest within one year of separation from service. 6. A chronic right hip disability was not incurred in service and did not manifest within one year of separation from service. 7. A chronic left hip disability was not incurred in service and did not manifest within one year of separation from service. 8. The Veteran does not have a currently diagnosed upper extremity nerve disorder; although he has symptoms those were not incurred in service and have not been shown to be caused or aggravated by a service-connected disability. 9. Lower extremity peripheral neuropathy was not incurred in service and has not been shown to be caused or aggravated by a service-connected disability. 10. The Veteran does not have a currently diagnosed disability manifested by sleep pattern changes. 11. The Veteran does not have chronic fatigue syndrome or another currently diagnosed disability manifested by fatigue. 12. Prior to November 14, 2013, audiograms of record showed hearing loss manifested by at worst Level III hearing acuity bilaterally; the evidence does not suggest that the Veteran's symptoms of hearing loss were not adequately contemplated by the rating criteria. 13. On and after November 14, 2013, the audiograms of record showed hearing loss manifested by at worst Level III hearing acuity in the right ear and Level IV hearing loss in the left ear; the evidence does not suggest that the Veteran's symptoms of hearing loss are not adequately contemplated by the rating criteria. 14. The Veteran's service-connected tinnitus is assigned a 10 percent rating, the maximum rating authorized under Diagnostic Code 6260; the evidence does not suggest that the Veteran's symptoms of tinnitus are not adequately contemplated by the rating criteria. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 2. The criteria for service connection for a back disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 3. The criteria for service connection for a neck disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 4. The criteria for service connection for a right knee disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2015). 5. The criteria for service connection for a left knee disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2015). 6. The criteria for service connection for a right hip disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2015). 7. The criteria for service connection for a left hip disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2015). 8. The criteria for service connection for a nerve disorder of the upper extremities are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2015). 9. The criteria for service connection for a nerve disorder of the lower extremities are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2015). 10. The criteria for service connection for a disability manifested by sleep pattern changes are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2015). 11. The criteria for service connection for chronic fatigue syndrome or a disability manifested by fatigue are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2015). 12. Prior to November 14, 2013, the criteria for an initial compensable rating for bilateral hearing loss were not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.85, 4.86 (2015). 13. On and after November 14, 2013, the criteria for a disability rating of 10 percent, but no higher, for bilateral hearing loss have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.85, 4.86 (2015). 14. The criteria for a disability rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.87, Diagnostic Code 6260 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist a claimant in the development of a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). VA must notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). Compliant notice was provided in April 2010. Following the Board's remand in May 2016, additional notice regarding the theory of secondary service connection was provided in a May 2016 letter. The Veteran's increased rating claims arise from his disagreement with the initial evaluations that were assigned following the grant of service connection in March 2012. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (section 5103(a) notice is no longer required after service-connection is awarded). Concerning the duty to assist, the Veteran's service treatment records, as well as post-service VA treatment records have been associated with the claims file, along with some private records provided by the Veteran. Following the Board's remand in May 2016, the Veteran was given the opportunity to provide authorization for VA to help him obtain records from private treatment providers or to submit those records himself. Following the remand, examinations were provided and medical opinions obtained in June and July 2016. The requirements of the Board's May 2016 remand have been fulfilled. See Stegall v. West, 11 Vet. App. 268 (1998). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b) (2015). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Under section 3.310 of VA regulations, service connection may also be established on a secondary basis for a disability which is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has reviewed the Veteran's entire record with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Acquired Psychiatric Disorder In March 2010, along with a claim for service connection, the Veteran submitted a statement from a Dr. N.O. indicating the Veteran had problems with his back, neck, hips and knees that were related to service and were currently causing him frustration, anxiety and irritability. It was noted he needed help at home with daily tasks and as a consequence, he had decreased interest and pleasure in most activities. In May 2016, the Board reopened a claim for service connection for an acquired psychiatric disorder based on treatment records showing complaints of psychiatric symptoms, to include anxiety and depression and the indication in Dr. N.O's statement that the symptomatology might be related to service. The claim was remanded for a VA examination. At the June 2016 VA examination, the VA examiner failed to diagnose a psychiatric disability. The examiner reviewed the claims file and interviewed the Veteran. He noted no evidence of psychiatric complaints, findings or treatment during or within one year after discharge from military service. The examiner noted the Veteran was alert and in contact with reality and his thought process was coherent and logical. The Veteran's mood was relaxed and appropriate. It was noted the Veteran had a successful marriage, had raised 5 children and had a successful social and retirement life since 2008. The examiner concluded that the Veteran did not fulfill the criteria for any DSM-V diagnosis. Although post-service records do contain treatment for depression and anxiety in 2000 and 2001, the existence of a current diagnosed disability is the cornerstone of a claim for service connection and VA disability compensation. 38 U.S.C.A. § 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the appellant currently has the disability for which benefits are being claimed. As there is no competent evidence that the Veteran has been diagnosed with a psychiatric disorder, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for an acquired psychiatric disorder must be denied. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 49; Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Back Disorder, Neck Disorder, Knee Disorders, Hip Disorders and Nerve Disorders Service treatment records do not contain complaints of or treatment for disabilities of the back, neck, knees or hips or any nerve disorders related thereto. In March 2010, along with a claim for service connection, the Veteran submitted a statement from Dr. N.O. that the Veteran injured his back during field work while in service. The doctor indicated the Veteran carried a lot of equipment and firearms on his back and started experiencing back pain while in the service that had aggravated with time. The doctor indicated that stress applied to the Veteran's back "during continuous use while realizing his duties" caused chronic inflammatory changes with subsequent degenerative problems. She stated this caused bad posture, loss of correct alignment and loss of curvature of the spine and as a consequence, the Veteran "could present disc bulging and herniation with degenerative problems." She also indicated that his neck and back were affected and secondary to them, degenerative changes "could be present in other articulations" such as the hips and knees. In addition, Dr. N.O. stated that problems of radiculopathy and neuropathy "could also be present." It was unclear if Dr. N.O. actually examined the Veteran and the Veteran did not provide authorization to seek additional records from Dr. N.O. following the Board's May 2016 remand. Following the Board's remand, the Veteran underwent VA examinations of the back, neck, bilateral knees, bilateral hips and peripheral nerves due to the indication that the Veteran suffered from current disabilities that might be related to service. In June 2016, the Veteran underwent an examination of his back. Lumbar degenerative disc disease and spondylosis were diagnosed. The Veteran indicated that he began having low back pain approximately eight years prior that was constant and severe. The examiner opined that the lumbar condition was less likely as not related to service because there was no evidence that the Veteran had any low back injury, any medical treatment or diagnosis regarding the lumbar spine during service. He opined that the current low back condition was due to normal progression of the aging process. The examiner noted that Dr. N.O. did not indicate review of the service treatment records or that she had performed a complete musculoskeletal examination. As to whether the current low back condition was aggravated beyond its natural progression by any of the Veteran's orthopedic conditions, to include in the knees or hips, the examiner indicated that it was less likely as not because the conditions were in different anatomical areas with different nerve supplies and bony structures that were unrelated to each other. In July 2016, the Veteran underwent an examination of his neck. Cervical strain was diagnosed. The Veteran indicated the condition began in service and indicated daily pain lasting hours. The examiner concluded the condition was less likely than not incurred in service because review of the claims file did not reveal evidence of trauma or treatment for a cervical condition in service. He concluded that the cervical condition was most likely due to aging. In June 2016, the Veteran underwent an examination of his bilateral knees. Degenerative arthritis was diagnosed in both knees. The Veteran reported that bilateral knee pain had increased slowly but steadily over the past 20 years. The examiner concluded the condition was less likely than not incurred in service or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran's September 1957 separation examination was negative for any type of knee condition and that degenerative changes of the knee joints were part of the normal aging process. In June 2016, the Veteran underwent an examination of his bilateral hips. Degenerative arthritis was diagnosed in both hips. The examiner noted the Veteran was 80 years old and indicated he had chronic hip pain, although he denied any problems while in the service. The Veteran denied any treatment during service, but stated he currently had constant pain in his hips that limited his ambulation. The examiner opined that the bilateral degenerative joint disease (DJD) to include enthesopathic changes of the pelvis and bilateral femoral trochanters is less likely than not related to military service. The examiner explained that the separation examination and the STRs were silent as to any hip problems and the Veteran himself denied hip problems while in service. She indicated that Dr. N.O's opinion was not based on review of the record and did not take into account the gap of 43 years following separation from service with a lack of chronicity of symptoms or treatment between service and diagnosis of arthritis in the hips. In addition, she indicated that DJD of the hips is a common condition for a person of 80 years and is "part and parcel of the natural aging process." The examiner also opined that the Veteran's hip condition was mild per radiologic evidence and treated with over-the-counter medications. She indicated it was as expected for an 80 year old and was less likely aggravated beyond natural progression by any other condition, to include of the back or knees. In June 2016, the Veteran underwent a VA examination of his peripheral nerves. He had moderate intermittent pain in his bilateral upper extremities and mild intermittent pain in his bilateral lower extremities. He had moderate paresthesias in the upper extremities, mild numbness in the upper extremities and moderate numbness in the lower extremities. It was also noted he had cramps in the legs and hands at night. Sensation was decreased in his lower legs and absent in his feet. The Veteran indicated these symptoms began 15 years prior. The examiner diagnosed lower extremity peripheral neuropathy and declined to make a diagnosis of a nerve disorder in the upper extremities. The examiner explained that the Veteran presented clinical evidence of lower extremity peripheral neuropathy symptoms that began 15 years ago, far removed temporally from service. The examiner could only speculate as to the etiology of the neuropathy in a non-diabetic patient, but she noted it was probably old age neuropathy. Regarding the possible aggravation of the lower extremities neuropathy by any orthopedic problem, the examiner noted that "neuropathies are entities caused by either metabolic derangements or intoxications with nocive [sic] substances, not problems involving the joints, unless a compressive process is invoked, which is not the case in this veteran." Overall, the preponderance of the evidence fails to demonstrate that any currently diagnosed disability of the back, neck, bilateral knees, bilateral hips or nerves of the upper or lower extremities was incurred during the Veteran's active duty service in the 1950s. The STRs are silent for any injuries of the back, neck, knees or hips or any treatment for symptomatology associated with the back, neck, knees or hips or the upper or lower extremities. At separation, spine, lower extremity, upper extremity, neurologic, and musculoskeletal examinations were normal and the Veteran had no musculoskeletal or neurologic complaints. Initial complaint of symptomatology affecting the back, neck, knees, hips and upper or lower extremities appear in the record many decades after separation from service. The long period of time that passed between the Veteran's period of active service and complaints regarding symptoms affecting the back, neck, knees, hips and upper or lower extremities weighs against a relationship between service and any currently diagnosed disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that a proper consideration for the trier of fact is the amount of time that has elapsed since military service). The Board acknowledges that where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis (or degenerative joint disease) becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). Here, evidence of arthritis did not become evident in the record until 2016, nearly 60 years after separation from service. In addition, the medical records do not show continuing treatment between service and the present for symptomatology concerning the back, neck, knees or hips. Although the Veteran indicated at his VA examinations that back pain began around 2008, hip pain was not present in service and upper and lower extremity symptoms began around 2000, the Board acknowledges the Veteran's contention, based on Dr. N.O's statement, that his orthopedic and upper and lower extremity concerns today are related to service. The Veteran is competent to report on matters observed or within his personal knowledge, and is therefore competent to make statements regarding his symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, a probative medical opinion on the etiology or underlying causes of back, neck, knee, hip conditions or conditions affecting the nerves requires the specialized training of a medical professional. In this case, as a layperson not shown to possess appropriate medical training and expertise, the Veteran is not competent to render a persuasive or competent medical opinion on whether a disability of the back, neck, knees or hips or a nerve disorder were caused by or are otherwise related to his military service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir 2006). Hence, his assertions in this regard cannot constitute competent and persuasive evidence in support of the claims for service connection. Upon review of the medical opinions of record, the Board finds that the VA examination opinions that were based on a review of the claims file and a direct examination of the Veteran are more probative than the opinion offered by Dr. N.O. who did not indicate review of the claims file or undertake an actual physical examination of the Veteran meant to identify what disabilities the Veteran currently had. Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail and whether there was review of the Veteran's relevant history. Prejean v. West, 13 Vet. App. 444 (2000). The Board recognizes that an examiner need not review the actual claims file; however, knowledge of the relevant history of the disability is a strong factor in determining the probative value of an opinion. In addition, an opinion based upon an inaccurate factual premise has no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Swann v. Brown, 5 Vet. App. 229 (1993)) (holding that the Board is not bound to accept medical opinions that are based upon an inaccurate factual premise); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board has authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence). Here, Dr. N.O. did not note the lack of evidence of injury or treatment for back, neck, knee, hip or upper or lower extremity concerns during the Veteran's period of service or the many decades after service in which the Veteran did not seek treatment. Dr. N.O.'s statements are conclusory and general and do not provide supporting rationale. Thus, his opinion is of little probative value. Because the preponderance of the evidence is against a finding that the Veteran's lumbar degenerative disc disease, spondylosis, cervical strain, peripheral neuropathy or symptoms of numbness and/or parathesias in the upper extremities were incurred in or are related to service, or that arthritis manifest in the bilateral knees or hips within one year of separation from active duty; the claims for service connection must be denied. In addition, as service connection is not in effect for any orthopedic disability, any claim for service connection on a secondary basis must fail. 38 C.F.R. § 3.310. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-56. Disabilities Manifested by Sleep Pattern Changes and Fatigue In Dr. N.O.'s March 2010 statement, filed along with the Veteran's claim for service connection, the doctor indicated that the Veteran had pain in his back, neck, knees and hips and presented with fatigue and changes in his sleep patterns due to physical ailments she related to his duties while in service. In May 2016, the Board remanded the claim for a psychiatric examination noting that VA treatment records indicated the Veteran reported problems sleeping in relation to his anxiety and depression. The Board asked the examiner to identify all psychiatric disorders present, along with any diagnosable sleep disorder. The Board indicated that if a sleep disorder was not diagnosed, the examiner should state whether the Veteran has any sleep related symptoms resulting from any diagnosed psychiatric condition. As mentioned, in June 2016, an examiner evaluated the Veteran and found that he did not meet the criteria for diagnosis of a psychiatric condition pursuant to the DSM-V. Currently, the record does not indicate that the Veteran has a diagnosed sleep disorder or that any sleep related symptoms are the result of a diagnosed psychiatric condition. Although not specifically sought on remand, the Veteran underwent a VA examination to determine whether he had a diagnosis of chronic fatigue syndrome. At the June 2016 examination, the examiner noted a lack of evidence of chronic fatigue in the Veteran's medical records or STRs. He noted the Veteran was 80 years old and indicated frequent shortness of breath. The Veteran reported having sinusitis which gave him problems with breathing through his nose. He indicated having a heart condition, but he denied lack of energy stating he was active around the home. He indicated he napped twice daily for short periods. The examiner identified some symptoms of chronic fatigue syndrome, to include generalized muscle aches or weakness, headaches and sleep disturbance, but he declined to render a diagnosis of the condition. The Veteran related his aches and pain, to include his back problems, to his age and his headaches to his sinusitis. Overall, the Board finds that the preponderance of the evidence fails to demonstrate that a disability manifested by sleep pattern changes or a disability manifested by fatigue were incurred in service or otherwise related thereto. The STRs are silent for problems with sleep or issues with fatigue during service and there is no evidence of chronic problems with sleep or fatigue in the intervening decades since separation from service in 1957. As previously stated, the existence of a current diagnosed disability is the cornerstone of a claim for service connection and VA disability compensation. 38 U.S.C.A. § 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the appellant currently has the disability for which benefits are being claimed. As there is no competent evidence that the appellant has been diagnosed with a disability manifested by sleep pattern changes or a disability manifested by fatigue, the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine does not apply, and the claims for service connection must be denied. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 49; Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). III. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ratings of hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests (Maryland CNC) combined with the average hearing threshold levels as measured by pure tone audiometric tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second. 38 C.F.R. § 4.85(a), (d). To rate the degree of disability for service-connected hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85(h), Tables VI, VIA (2015). In order to establish entitlement to a compensable rating for hearing loss, certain minimum levels of the combination of the percentage of speech discrimination loss and average pure tone decibel loss must be met. The results of the pure tone audiometric test and speech discrimination test are charted on Table VI, Table VIA, in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII, as set out in the Rating Schedule. 38 C.F.R. § 4.85. Table VIA will be used when the examiner certifies that use of the speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when an exceptional pattern of hearing loss is shown, specifically when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. When the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more in a particular ear, determination of the level of hearing acuity in that ear will be made using either Table VI or Table VIA, whichever results in the higher numeral. Id. In addition to dictating objective test results on a VA audiological examination report, the audiologist must fully describe the functional effects caused by a hearing disability. Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran initially sought service connection for hearing loss in March 2010. He submitted a statement from a Dr. N.O. who noted the Veteran had to listen to the television and radio at louder than normal volumes and people had to repeat themselves when speaking to him. In addition, the doctor noted that it was difficult for the Veteran to understand a conversation in a crowd and had to look at the person speaking or be very close to them. The doctor reported that the Veteran's daughter helped him to answer the phone and attend appointments because of his difficulty hearing. At a December 2011 VA examination, the Veteran indicated he had difficulty understanding conversational speech, mainly in the presence of background noise. An audiogram yielded the following results with pure tone thresholds, measured in decibels: 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 50 50 70 75 Left Ear 50 60 70 75 The average decibel loss was 61 decibels in the right ear and 64 decibels in the left ear. Speech discrimination scores were 90 percent in the right ear and 86 percent in the left ear. Based on Table VI, the Veteran had Level III hearing acuity bilaterally. Applying Table VII, the Veteran had noncompensable hearing loss at the December 2011 examination. On November 14, 2013, the Veteran underwent a VA Audiology Assessment Consult. He complained of decreased speech recognition ability. An audiogram yielded the following results with pure tone thresholds, measured in decibels: 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 50 55 65 65 Left Ear 55 55 70 70 The average decibel loss was 58.75 decibels in the right ear and 62.5 decibels in the left ear. Speech discrimination scores were 88 percent in the right ear and 84 percent in the left ear. Based on Table VI, the Veteran had Level III hearing acuity bilaterally which would support a noncompensable rating. However, the audiogram results represent exceptional hearing impairment in the left ear pursuant to 38 C.F.R. § 4.86. As such, applying Table VIA, the Veteran had Level IV hearing loss in the left ear. Applying Table VII, the evidence supported a 10 percent rating for bilateral hearing loss on November 14, 2013. Even if the Board rounded up the pure tone finding average of 62.5 to 63, which would indicate Level V hearing under Table VIA, a higher rating would not be warranted as Level III and Level V findings applied to Table VII result in a 10 percent rating. See id. On December 3, 2013, the Veteran was fitted for hearing aids. In a November 2014 rating decision, the RO increased the Veteran's rating for hearing loss to 10 percent, effective December 3, 2013. In May 2016, the Board remanded the claim recognizing that the Veteran's most recent VA audiological examination was in December 2011 and that a November 2013 VA audiology consultation note indicated that pure tone thresholds had worsened at some frequencies. In June 2016, the Veteran underwent another VA examination. He described difficulty understanding conversation speech in the presence of background noise and indicated that hearing loss affected his social interactions. An audiogram yielded the following results with pure tone thresholds, measured in decibels: 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 45 55 70 65 Left Ear 50 55 65 70 The average decibel loss was 59 decibels in the right ear and 60 decibels in the left ear. Speech discrimination scores were 92 percent in the right ear and 88 percent in the left ear. Based on Table VI, the Veteran had Level II hearing acuity in the right ear and Level III hearing acuity in the left ear. Exceptional hearing loss was not shown in either ear. Applying Table VII, the evidence does not support a disability rating in excess of 10 percent for bilateral hearing loss. Overall, the Board finds that prior to November 14, 2013, the criteria for a compensable rating for bilateral hearing loss were not met. However, on November 14, 2013, the evidence reflected exceptional hearing loss in the left ear and supported the grant of a 10 percent disability rating. At no time during the appeal period has the evidence supported a rating higher than 10 percent for hearing loss. The Board has carefully considered the lay statements submitted by the Veteran regarding his inability to hear well. The Veteran is certainly competent to describe his hearing loss. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the Veteran's description of his service-connected disability must be considered in conjunction with the clinical evidence of record. The Board emphasizes again that disability ratings for hearing loss are derived by a mechanical application of the rating schedule. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). As to tinnitus, the Veteran has been assigned a 10 percent rating under 38 C.F.R. § 4.87, Diagnostic Code 6260. The maximum schedular rating for this particular disability is 10 percent. 38 C.F.R. § 4.87, Diagnostic Code 6260. As such, the Veteran has been assigned the maximum schedular rating available for tinnitus for the entire appeal period. Id. There is no other appropriate diagnostic code for which a higher rating could be awarded. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture so as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2015); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the established schedular criteria are inadequate to describe the severity and symptoms of the claimant's disability. See Thun v. Peake, 22 Vet. App. 111, 118 (2008). Tinnitus is a noise in the ears, such as ringing, buzzing, roaring, or clicking. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1914 (30th ed. 2003). The Veteran has reported that his tinnitus is intermittent and can distract him, and affect concentration and his ability to rest and sleep. As these difficulties are the result of the noise the Veteran perceives in his ears, which is contemplated by the rating assigned under Diagnostic Code 6260, extraschedular consideration is not warranted. See 38 C.F.R. § 4.87, Diagnostic Code 6260. Moreover, the Veteran has not described any interference with employment, let alone marked interference with employment, hospitalization, or any other governing norm as a result of his tinnitus. See 38 C.F.R. § 3.321(b)(1). Simply put, the symptoms and effects of the symptoms described by the Veteran are not unusual or exceptional for someone suffering from tinnitus. The Board is of the opinion that the rating schedule measures and contemplates each aspect of the Veteran's hearing loss disability. As explained in the proposed rule for the current version of Diagnostic Code 6100, the criteria of Diagnostic Code 6100 were revised in 1987 with the goal of recognizing the impact of hearing loss in higher frequencies, and to provide a more accurate picture of true hearing impairment. See 52 Fed. Reg. 17607 (May 11, 1987). As a result, VA changed its testing methods and, in conjunction with the Department of Medicine and Surgery, developed amendments to 38 C.F.R. §§ 4.85, 4.86a, 4.87a and Tables VI and VII. In particular, pure tone averaging was to be accomplished using tone bursts at 1000, 2000, 3000 and 4000 Hertz, and speech recognition was to be measured using the Maryland CNC word lists which contained words with sounds in the 3000 and 4000 Hertz range. Overall, the new schedule was intended to evaluate hearing loss based on a combination of pure tone averages and speech discrimination, which was thought to provide for a more accurate representation of actual hearing impairment by recognizing that individuals with slight to moderate decibel loss as determined by pure tone averaging may have significant impairment of speech and vice versa. Additionally, the rating schedule was revised to accommodate language difficulties and other factors which produced inconsistent speech audiometry scores and to recognize exceptional patterns of hearing impairment. Notably, VA determined that "Table VII was developed during months of consultations with our Department of Medicine and represents the best judgment of experts in this field." Based upon the stated factors and considerations undertaken by VA and medical experts in developing the current criteria of Diagnostic Code 6100, the Board finds that the schedular rating currently assigned reasonably describes the Veteran's disability level and symptomatology. The Veteran's description of difficulty hearing has been measured according to pure tone averages and speech discrimination. The Board recognizes that the Veteran stated it was difficult to understand people and he had to ask them to repeat. However, as explained above, the rating criteria are designed to take into account testing that accurately measures difficulty hearing in an objective way and the Veteran's reports simply do not represent an exceptional case. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. The United States Court of Appeals for Veterans Claims (Court) in Yancy v. McDonald, 27 Vet. App. 484, 495 (2016), subsequently held that 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. Neither scenario applies to the instant case as the Veteran is only service-connected for hearing loss and tinnitus. As a final matter, the Board acknowledges that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is raised by the record. Here, the Veteran does not contend and the evidence does not show that he is unable to maintain or sustain substantially gainful employment because of his hearing loss or tinnitus. Accordingly, the Board finds that no further action pursuant to Rice is necessary. ORDER Service connection for an acquired psychiatric disorder is denied. Service connection for a back disorder is denied. Service connection for a neck disorder is denied. Service connection for a right knee disorder is denied. Service connection for a left knee disorder is denied. Service connection for a right hip disorder is denied. Service connection for a left hip disorder is denied. Service connection for a nerve disorder of the upper extremities is denied. Service connection for a nerve disorder of the lower extremities is denied. Service connection for a disability manifested by sleep pattern changes is denied. Service connection for chronic fatigue syndrome or a disability manifested by fatigue is denied. Prior to November 14, 2013, a compensable disability rating for bilateral hearing loss is denied. On and after November 14, 2013, entitlement to a disability rating of 10 percent, but no higher, for bilateral hearing loss is granted, subject to controlling regulations governing the payment of monetary awards. A disability rating in excess of 10 percent for tinnitus is denied. ____________________________________________ Nathan Kroes Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs