Citation Nr: 1702732 Decision Date: 02/01/17 Archive Date: 02/15/17 DOCKET NO. 15-19 172 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to service connection for a cervical spine disability. 2. Entitlement to service connection for bilateral carpal tunnel syndrome. 3. Entitlement to service connection for a bilateral hip disability. 4. Entitlement to service connection for a condition of the nervous system. 5. Entitlement to an initial compensable disability rating for erectile dysfunction. (The appeal of entitlement to an initial evaluation in excess of 10 percent for a left knee disability prior to January 15, 2016 and in excess of 20 percent thereafter as well as entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) will be addressed in a separate decision). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Arif Syed, Counsel INTRODUCTION The Veteran had active service from July 1962 to May 1983. Service in the Republic of Vietnam is indicated by the record. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. The Veteran is represented by Disabled American Veterans in these matters. However, as the Veteran has an attorney only for the issues of entitlement to an increased disability rating for a left knee disability and entitlement to TDIU, those issues will be addressed in a separate Board decision. On the Veteran's substantive appeal dated June 2015 regarding his erectile dysfunction claim as well as his substantive appeal dated August 2015 regarding his cervical spine disability, bilateral carpal tunnel syndrome, bilateral hip disability, and nervous system claims, he requested a hearing before a VLJ. However, he cancelled his hearing request in April 2016. Accordingly, his request for a hearing is considered to be withdrawn and his claim will be reviewed based on the evidence of record. See 38 C.F.R. § 20.704(e) (2016). The Board has reviewed the record maintained in the Veteran's Virtual VA paperless claims processing system folder. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The issues of entitlement to service connection for bilateral carpal tunnel syndrome and condition of the nervous system are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran does not have a current diagnosis of a bilateral hip disability, nor has he at any time during the claim and appeal period. 2. The Veteran's currently diagnosed cervical spine disability is not related to his service. 3. The Veteran does not have penile deformity. CONCLUSIONS OF LAW 1. Entitlement to service connection for a bilateral hip disability is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2016). 2. Entitlement to service connection for a cervical spine disability is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2016). 3. The criteria for a compensable initial rating for erectile dysfunction have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.31, 4.115b, Diagnostic Code 7522 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to service connection for a cervical spine disability and a bilateral hip disability as well as entitlement to an increased disability rating for erectile dysfunction. In the interest of clarity, the Board will discuss certain preliminary matters. The issues on appeal will then be analyzed and a decision rendered. The Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA) includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also defines the obligations of VA with respect to its statutory duty to assist a claimant in the development of his claim. See 38 U.S.C.A. §§ 5103, 5103A (West 2014). VA must notify the claimant of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Veteran was provided with the required notice, to include notice with respect to the disability rating and effective-date elements of the claim, by a letter mailed in July 2008, prior to the initial adjudication of his claims. The Board notes that the claim for initial increased disability rating for erectile dysfunction is a downstream issue from a rating decision dated September 2013, which initially established service connection for this disability and assigned the initial rating and its effective date. The United States Court of Appeals for Veterans Claims (Court) held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006), that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008). Thus, to the extent that there is any noncompliance with the statutorily prescribed VCAA notice requirements with respect to the claim for an initial increased disability rating for erectile dysfunction, such noncompliance is deemed to be non-prejudicial to this specific claim. In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law affords that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2016). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims and there is no reasonable possibility that further assistance would aid in substantiating these claims. The evidence of record includes statements from the Veteran and other individuals, service treatment records, Social Security Administration (SSA) records, and postservice VA and private treatment records. The Veteran was afforded VA examinations for his erectile dysfunction in September 2013 and October 2014. The examination reports reflect that the examiners interviewed and examined the Veteran, reviewed his past medical history, documented his current medical conditions, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. Furthermore, the September 2013 and October 2014 examination reports contain sufficient information to rate the Veteran's erectile dysfunction under the appropriate diagnostic criteria. The Board therefore concludes that the VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2016); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. The Board notes that the Veteran was not provided examinations and nexus opinions for his cervical spine disability and bilateral hip disability claims. Under 38 C.F.R. § 3.159(c)(4) (2016), VA will provide a medical examination or opinion if the information and evidence of record does not contain sufficient medical evidence for VA to make a decision on the claim but: (1) contains competent lay or medical evidence that the claimant has a current diagnosed disability, or persistent or recurring symptoms of disability; (2) establishes that the Veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service. See 38 U.S.C.A. § 5103A(d) (West 2014); 38 C.F.R. § 3.159(c)(4) (2016); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board further finds that there is sufficient evidence to decide these claims, and that further medical examination or opinion is not necessary to decide the claims for service connection for a cervical spine disability and bilateral hip disability. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). In the present case, as discussed in further detail below, the competent and probative evidence does not show or indicate that the Veteran has a current bilateral hip disability. Further, the competent and probative evidence does not show or indicate that the Veteran sustained an in-service disease or injury resulting in his current cervical spine disability. Accordingly, VA examinations for these claims are not warranted. The facts of this case are different than the facts in Charles v. Principi, 16 Vet. App. 370 (2002), in which the Court held that VA erred in failing to obtain a medical nexus opinion where evidence showed acoustic trauma in service and a current diagnosis of tinnitus. Significantly, in this case, there is no competent and probative evidence which supports evidence of a current bilateral hip disability as well as evidence of in-service disease or injury resulting in current cervical spine disability. Thus, the Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. Accordingly, the Board will proceed to a decision as to the issues of entitlement to service connection for a bilateral hip disability and cervical spine disability as well as entitlement to increased disability rating for erectile dysfunction. Service connection for a bilateral hip disability The Veteran contends that he has a bilateral hip disability that is related to his service. The Board also notes that the Veteran has not claimed that his bilateral hip disability was associated with exposure to herbicides during service, nor does the evidence of record otherwise reflect such. Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2016). In order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). For certain chronic disorders, including arthritis, service connection may be presumed to have been incurred in service if the disease becomes manifest to a compensable degree within one year following separation from service. See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309(a) (2016). Service connection presupposes a diagnosis of a current disability. See Rabideau v. Derwinski, 2 Vet. App. 141 (1992). A "current disability" means a disability shown by competent medical evidence to exist. See Chelte v. Brown, 10 Vet. App. 268 (1997). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact or chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2016). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2014). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2016). With respect to element (1), current disability, the competent medical evidence of record does not demonstrate that the Veteran is currently diagnosed with a bilateral hip disability. The Board wishes to make it clear that it has no reason to doubt that the Veteran experiences certain symptoms such as pain in his hips. However, symptoms alone, without a diagnosed or identifiable underlying malady or condition, do not constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). Pertinently, in this case, the evidence does not support a finding that the symptoms that the Veteran has reflect a disability of the hips. The record does not show a diagnosis of a hip condition. While an October 2012 statement of Dr. Bash noted that the Veteran's complaints included " right leg numbness and tingling traveling from the hip area down the thigh to the right knee, those symptoms were attributed to the service-connected lumbar spine disability and there was no diagnosis of a hip condition rendered on the report. With regard to lay statements made by the Veteran in connection with his claim, in relevant part, 38 U.S.C.A. 1154(a) (West 2014) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). The Board notes that the Veteran, while entirely competent to report his symptoms both current and past, including pain, as a lay person he is not competent to associate any of his claimed symptoms to a bilateral hip disability. Such opinion requires specific medical training in the field of orthopedics and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran has the specific medical training in the field of orthopedics to render medical opinions, the Board must find that his contention with regard to a diagnosis of a bilateral hip disability to be of minimal probative value and outweighed by the objective evidence which is absent a finding of such. See also 38 C.F.R. § 3.159(a)(1) (2016) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. Accordingly, the statements offered by the Veteran in support of his own claims are not competent evidence of a disability of the hips. Because the weight of the evidence of record does not substantiate a current diagnosis of a bilateral hip disability, the first element of service connection is not met, and service connection is therefore not warranted on that basis as to this claim. See Degmetich v. Brown, 104 F.3d 132 (Fed. Cir. 1997); see also Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) [service connection cannot be granted if the claimed disability does not exist]. In conclusion, for the reasons and bases expressed above, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a bilateral hip disability. The benefit sought on appeal is accordingly denied. Service connection for a cervical spine disability The law and regulations pertaining generally to service connection have been set forth above and will not be repeated here. The Board initially notes that the record does not reflect medical evidence showing any manifestations of arthritis of the cervical spine during the one-year presumptive period after the Veteran's separation from service. On the contrary, the record does not reflect any complaints or findings consistent with this disability until May 1996 (more than 10 years after his separation from active service). Accordingly, service connection is not warranted on a presumptive basis as to this claim. 38 C.F.R. §§ 3.307, 3.309. Having determined that presumptive service connection is not warranted, the Board's inquiry turns to whether service connection on a direct basis is warranted. As noted above, in order for service connection to be granted, three elements must be present: (1) a current disability; (2) in-service incurrence of disease or injury; and (3) nexus. See Hickson, supra. As a preliminary matter, the Board notes that the Veteran has not claimed that his cervical spine disability was associated with exposure to herbicides during service, nor does the evidence of record otherwise reflect such. As to Hickson element (1), the competent and probative evidence of record documents diagnosis of degenerative changes of the cervical spine. See, e.g., a private treatment record from R.D., M.D. dated September 2003. Hickson element (1) is therefore satisfied as to this claim. Turning to element (2), in-service incurrence of an injury or disease, to the extent that the Veteran contends that his cervical spine disability is related to his service, the Board finds that the competent and probative evidence of record outweigh these contentions. His service treatment records, to include his April 1983 retirement examination, indicate no suggestion of treatment for a cervical spine disability. On the contrary, the earliest document showing a history of a diagnosis or symptoms of a cervical spine disability dating back to service is in 1996. This is more than 10 years after his separation from service. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) [contemporaneous evidence has greater probative value than history as reported by the veteran]; see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) [noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised]. The Board observes that 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 (e.g. any evidence not requiring that the proponent has specialized education, training, or experience). 38 C.F.R. § 3.159(a)(2). As such, the Veteran can competently testify about symptoms he experienced in service. However, competency must be distinguished from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In the present case, the Board finds that the Veteran's history of a cervical spine disability since service is outweighed by the objective evidence of record in light of both the lack of any post service treatment or complaints of this disability until 1996. Accordingly, to the extent that the Veteran contends that his cervical spine disability manifested during service, this contention is at odds with the remainder of the record, which is devoid any indication that any injury or disease occurred during service or for more than 10 years thereafter. As such, the Veteran's statements are lacking probative value. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) [VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence]. In short, the weight of the evidence does not demonstrate an in-service diagnosis of a cervical spine disability or symptomatology attributed therewith. Element (2) is therefore not met, and the Veteran's claim fails on this basis. For the sake of completeness, the Board will discuss element (3), nexus. See Luallen v. Brown, 8 Vet. App. 92, 95-6 (1995), citing Holbrook v. Brown, 8 Vet. App. 91, 92 (1995) [the Board has the fundamental authority to decide a claim in the alternative]. There is no competent evidence of record that establishes a causal relationship between the Veteran's currently diagnosed cervical spine disability and his service. In the absence of in-service disease or injury, it would seem that such nexus opinion would be impossible. In relevant part, 38 U.S.C.A. 1154(a) (West 2014) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson, supra. "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau, supra; see also Buchanan, supra ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). The Board notes that the Veteran, while entirely competent to report his symptoms both current and past, including neck pain, has presented no competent evidence of a nexus between his cervical spine disability and his service. The Board finds that the Veteran as a lay person is not competent to associate any of his claimed symptoms to his service. That is, the Veteran is not competent to opine on matters such as the etiology of his current cervical spine disability. Such opinion requires specific medical training in the field of orthopedics and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran has the medical training in the field of orthopedics sufficient to render medical opinions, the Board must find that his contention with regard to a nexus between his cervical spine disability and service to be of no probative value. See 38 C.F.R. § 3.159(a)(1) (2016) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. Accordingly, the statements offered by the Veteran in support of his own claim is not competent evidence of a nexus. The Board is aware of the provisions of 38 C.F.R. § 3.303(b), discussed above, relating to chronicity and continuity of symptomatology. To the extent that the Veteran contends that he has had a cervical spine disability to include arthritis continually since service, the first postservice evidence of complaint of, or treatment for this disability is in 1996. See a private treatment record from D.S., M.D. dated May 1996. This was more than 10 years after the Veteran left service in May 1983. The Board finds that the probative value of the Veteran's current statements regarding a continuity of symptoms related to a cervical spine disability since service are outweighed by the remainder of the evidence of record. In particular, the Board reiterates that a cervical spine disability or residuals thereof was not reported at the time of his service discharge. His April 1983 retirement examination from service as well as the medical evidence of record outweigh any current assertion that his current cervical spine disability was manifested during service. There is no competent medical evidence that the Veteran complained of or was treated for a cervical spine disability for many years after his separation from service. The Board accordingly places no probative value on the assertions of the Veteran that there has been a continuity of symptomatology dating to service. Therefore, continuity of symptomatology after service is not demonstrated. Accordingly, element (3) is not met, and the Veteran's claim also fails on this basis. For the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a cervical spine disability. The benefit sought on appeal is accordingly denied. Higher evaluation for erectile dysfunction Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(a), 4.1 (2016). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4 (2016). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2016). The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran was granted service connection for erectile dysfunction and a noncompensable rating was thereto pursuant to 38 C.F.R. § 4.115b, Diagnostic Codes 7599-7522. There is no diagnostic code which deals with erectile dysfunction exclusively. Diagnostic Code 7522 concerns penis deformity, with loss of erectile power. Under Diagnostic Code 7522, a 20 percent rating is assigned for deformity of the penis with loss of erectile power. No other disability rating is provided. See 38 C.F.R. § 4.115b, Diagnostic Code 7522. In every instance where the minimum schedular evaluation requires residuals and the schedule does not provide for a zero percent rating, a zero percent rating will be assigned when the required symptomatology is not shown. 38 C.F.R. § 4.31 (2016). The Veteran is seeking a compensable initial rating for his service-connected erectile dysfunction. The Board observes that, during the pendency of this appeal, the Veteran was granted special monthly compensation under 38 U.S.C. § 1114(k) due to loss of use of a creative organ. In order for a compensable rating to be assigned under Diagnostic Code 7522, deformity of the penis must be demonstrated. Pertinently, during September 2013 and October 2014 VA genitourinary examinations, the Veteran declined examination of his penis, testes, and epididymis and reported that such anatomy was normal. Moreover, the examiners noted that examination of the Veteran's prostate was not necessary as this was not relevant to the Veteran's erectile dysfunction. There are no medical findings of record contrary to the September 2013 and October 2014 VA genitourinary examination reports. Therefore, the evidence does not show and the Veteran does not otherwise assert that he experiences penile deformity. For the reasons stated above, the preponderance of the evidence is against a compensable initial rating for the Veteran's erectile dysfunction. Thus, the benefit-of-the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Generally, evaluating a disability using either the corresponding or an analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2016). Because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but, nevertheless, would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2016). The threshold factor for extraschedular consideration is a finding that the evidence resents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. See Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the applicable criteria reasonably describe the Veteran's disability level and symptomatology, the Rating Schedule contemplates then the Veteran's disability picture, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not unusual or exceptional in nature as to render the assigned rating inadequate. The Veteran's service-connected erectile dysfunction is evaluated analogously pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7522, and separately as loss of use of creative organ with respect to special monthly compensation. The Veteran's service-connected erectile dysfunction is manifested by loss of power, but not penile deformity. The Veteran has not asserted, and the evidence of record does not otherwise support finding, that his erectile dysfunction is manifested by symptoms other than loss of power. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that manifestations of the Veteran's service-connected erectile dysfunction contemplated by the disability picture represented by a noncompensable rating, with consideration of special monthly compensation for loss of use of a creative organ. Compensable ratings are provided for certain manifestations of erectile dysfunction, but the evidence demonstrates that those manifestations are not present here. Consequently, the Board concludes that a schedular evaluation is adequate and that referral of this issue for extraschedular consideration is not required. See 38 C.F.R. § 4.115(b), Diagnostic Codes 7522; see also Thun, 22 Vet. App. at 115; VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). 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. See Johnson v. Shinseki, 26 Vet. App. 237, 246 (2013) (en banc). However, in this case, the evidence of record, including lay statements, does not indicate any effect caused by a combination of the disability on appeal and any other service-connected disabilities that is not already specifically contemplated by the individually assigned ratings. The Board acknowledges that service connection has been granted for several other disabilities. As the Veteran has not raised the issue of extraschedular rating due to the combined effects of his service-connected disabilities, and this issue is not raised by the evidence of record, further discussion of an extraschedular rating based upon the combined effect of multiple conditions is not necessary. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016) (holding 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"). In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against a compensable initial rating for erectile dysfunction, there is no reasonable doubt to be resolved, and the doctrine is not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-6. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for a bilateral hip disability is denied. Entitlement to an initial compensable disability rating for erectile dysfunction is denied. REMAND With respect to the Veteran's claims of entitlement to service connection for bilateral carpal tunnel syndrome and a condition of the nervous system, he contends that these disabilities are related to his service. The Board notes that the medical evidence of record documents diagnoses of bilateral carpal tunnel syndrome as well as a general condition of the nervous system. See a private treatment record from R.G., M.D. dated July 1996; see also a private treatment record from R.D., M.D. dated September 2003. The Board also notes that the Veteran's April 1983 report of medical history in conjunction with his service retirement examination documents a report of wrist pain particularly in the right wrist. Although his service treatment records are absent complaints of or treatment related to general condition of the nervous system, the Board notes that Dr. R.D. reported in his September 2003 treatment record that the Veteran has "pins and needles" with numbness feeling that is related to his service-connected lumbar spine arthritis as well as throughout the vertebral column. There is no medical opinion currently associated with the Veteran's VA claims folder that offers an opinion as to a possible causal relationship between the Veteran's bilateral carpal tunnel syndrome and general condition of the nervous system and his period of service. In light of the ambiguities above, the Board is of the opinion that a VA examination would be probative in ascertaining whether the Veteran's current bilateral carpal tunnel syndrome and general condition of the nervous system are related to his active service. See 38 C.F.R. § 3.159(c)(4) (2016) (holding a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient medical evidence to decide the claim). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded an appropriate VA examination to determine the nature and etiology of his bilateral carpal tunnel syndrome and general condition of the nervous system. The Veteran's claims folder must be made available to the examiner prior to the examination. All tests and studies deemed necessary by the examiner should be performed. Based on a review of the claims folder and the clinical findings of the examination, the examiner must: a. Identify whether the Veteran currently has bilateral carpal tunnel syndrome. In making such determination, the examiner should address the July 1996 private treatment record from Dr. R.G. noting an impression of bilateral carpal tunnel syndrome. b. If bilateral carpal tunnel syndrome is identified, provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the disability is related to the Veteran's period of service, to include his complaint of wrist pain, in particular the right wrist, on his April 1983 report of medical history in conjunction with his service retirement examination. c. Identify whether the Veteran currently has a disability of the nervous system claimed as general condition of the nervous system. In making such determination, the examiner should address the September 2003 private treatment record from Dr. R.D. indicating a diagnosis of general condition of the nervous system. d. If a disability is identified, provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the disability is related to the Veteran's period of service. e. Is it at least as likely as not that the Veteran's Disability of the nervous system, claimed as general condition of the nervous system, is due to or caused by the service-connected lumbar spine arthritis. f. Is it at least as likely as not that the Veteran's disability of the nervous system is aggravated by his lumbar spine arthritis. Aggravation means an increase in the severity of the disability that is beyond natural progression. If aggravation is found, the examiner should address the following medical issues to the extent possible: (1) the baseline manifestations of the Veteran's general condition of the nervous system found prior to aggravation; and (2) the increased manifestations which, in the examiner's opinion, are proximately due to the lumbar spine arthritis. The examiner should indicate in his/her report that the claims file was reviewed. A rationale for all opinions expressed should be provided. A report should be prepared and associated with the Veteran's VA claims folder. In providing the requested opinion, the examiner should be advised that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. 2. When the development requested has been completed, the case should be reviewed on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case (SSOC) and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ K.J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs