Citation Nr: 1750169 Decision Date: 11/06/17 Archive Date: 11/17/17 DOCKET NO. 13-28 962A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office (RO) in Detroit, Michigan THE ISSUES 1. Entitlement to a compensable disability rating for bilateral hearing loss. 2. Entitlement to a disability rating in excess of 10 percent for lumbar spine disability (low back disability). 3. Entitlement to service connection for right knee replacement (knee disability), to include as secondary to service-connected lumbar spine disability. 4. Entitlement to service connection for osteoarthritis of the bilateral hips (bilateral hip disability), to include as secondary to service-connected lumbar spine disability. 5. Entitlement to service connection for achilles tendonitis of the left foot (left foot disability) 6. Entitlement to Total Disability Individual Unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD P. Meehan, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1959 to January 1963. This appeal comes before the Board of Veteran's Appeals (Board) from November 2011 and March 2012 rating decisions of the RO in Detroit, Michigan. In May 2017, the Veteran presented testimony at a Board hearing, chaired by the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. The Board notes that the RO separately adjudicated and denied the issues of : 1) entitlement to a disability rating in excess of 10 percent for low back disability, and 2) entitlement to TDIU. As they were properly on appeal before the Board prior to these adjudications, they do not impact the Board's current jurisdiction over them. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issue of a compensable disability rating for bilateral hearing loss, and the issue of entitlement to TDIU are addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's low back disability has been manifested by painful motion with forward flexion is measured to 70 degrees; extension measured to 20 degrees; right and left lateral flexion measured to 20 degrees; right and left rotation measured to 20 degrees, combined range of motion measured to 170 degrees; there are no neurological abnormalities associated with the lumbar spine. 2. The Veteran's right knee disability was not incurred in service and is not proximately due to or a result of a service-connected disability. 3. The Veteran's bilateral hip disability was not incurred in service and is not proximately due to or a result of a service-connected disability. 4. The Veteran's left foot disability is unrelated to service. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 10 percent for the service-connected lumbar spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2016). 2. The Veteran's right knee disability was not incurred in service and are not proximately due to or a result of a service-connected disability; arthritis is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2016). 3. A bilateral hip disability was not incurred in service and is not proximately due to or a result of, or aggravated by, a service-connected disability; arthritis is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2016). 4. The criteria for service connection for a left foot disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Rating Claims Disability ratings are determined by evaluating the extent to which a veteran-claimant's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. All reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. It is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Low Back Disability In a November 2011 rating decision, VA granted service connection for a lumbosacral spine disability characterized as "traumatic arthritis lumbosacral spine" and assigned an initial rating of 10 percent, effective January 3, 2011. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (Diagnostic Codes 5235-5243). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. A rating of 100 percent requires unfavorable ankylosis of the entire spine. A rating of 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine. A rating of 40 percent requires forward flexion of the thoracolumbar spine limited to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A rating of 20 percent requires forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A rating of 10 percent is assigned with forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. Ankylosis is defined, for VA compensation purposes, as a condition in which all or part of the spine is fixed in flexion or extension. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Formula, Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Formula, Note (2) (See also Plate V). For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37 VA afforded an initial examination for the Veteran's back and right knee (discussed below) in August 2014. The Veteran reported history of back pain at least 20 years, and numbness in his lower extremities on a frequent basis. He explained that his back pain is constant, and sometimes excrutiating. The Veteran reported no flare-up that impact the function of his back. Range of motion tests reveal, forward flexion from 0 to 65 degrees; extension from 0 to 20 degrees; right and left lateral flexion from 0 to 20 degrees; and right and left lateral rotation from 0 to 20 degrees. It was noted that the Veteran performed the range of motion tests with 3 repetitions, with no additional limitation in range of motion following repetitive testing. However, the examiner concluded that there was functional loss or functional impairment based on the Veteran's disability with contributing factors such as less movement than normal, pain on movement, and interference with sitting, standing, and/or weight bearing. Local tenderness was acknowledged as minimal at the lower para lumbar area. While the Veteran does have muscle spasms of the back, they did not result in an abnormal gait or spinal contour. No guarding of the spine was found, and there were no signs of muscle atrophy. In regard to neurological symptoms associated with the Veteran's back disability, the examiner concluded that there were none. There was no signs of radiculopathy, ankylosis, or other neurologic abnormalities or findings related to the Veteran's back. Finally, the Veteran's back disability was not found to impact his ability to work. An additional VA examination was provided in July 2017. The associated report reveals that the Veteran experienced a long history of back pain, and that his bending activity is limited when picking up things from the floor or completing other tasks like putting on socks. It was noted there was pain that radiates to the right leg with numbness off and on, full muscle strength, no history of incontinence, no intervertebral disc syndrome, and no thoracic vertebral fracture with loss of 50 percent or more of height. The Veteran reported functional loss and described how prolonged walking, standing, sitting or frequent bending increases plain. Range of motion tests reveal, forward flexion from 0 to 70 degrees; extension from 0 to 20 degrees; right and left lateral flexion from 0 to 20 degrees; and right and left rotation from 0 to 20 degrees. These results were noted as abnormal, and that there was evidence of paint with weight bearing with objective evidence of slight localized tenderness over the lumbar vertebra at L4, L4, and SI. The examiner did not examine the Veteran immediately after repetitive use over time or doing a flare-up, and stated that any comments regarding pain, weakness, fatigability, or incoordination limiting functional ability would be mere speculation. However, the examination report does state that the Veteran was able to complete at least three repetitions, and that there is was no additional loss of function or range of motion of the three repetitions of the range of motion testing on the spine. In addition the examiner concluded there was no evidence of limiting function abilities with flare-ups, guarding or muscle spasm of the back, muscle atrophy, radiculopathy, ankylosis, or other neurological abnormalities. The examiner also reported an objective impression of moderate multilevel lumbar spine degenerative changes, and noted that the Veteran's low back disability impacted his ability to work because prolonged standing, walking, sitting, and frequent bending increase his lower back pain, which ultimately limits his activity at his lower back. The examiner also indicated that while there are subjective symptoms of pain and numbness in the right lower extremity, the neurological examination was normal. As to the Board's duty to assist, the Board acknowledges that for an adequate VA examination, joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016). In addition, assignment of a disability rating should take into account consideration of limitation of functional ability during flare-ups or when a joint is used repeatedly over a period of time. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). However, even if it was found that the July 2017 examination did not fully comply with the holdings above because the Veteran was not examined after repetitive use over time, the Board finds that further development would be unnecessary as the deficiency would not be prejudicial to the Veteran. In addition to testing, the Veteran has been asked to describe functional loss and impairment in various situations and he has not identified that he has loss of motion to the degree required for a higher rating. In addition, repetitive range of motion testing was performed in the initial August 2014 VA examination. Simply put, after taking into account the consistent medical findings and the lay statements, the evidence does not suggest that motion is limited to the requisite degree for a higher rating at any point. Based on the clinical findings and the Veteran's assertions as recorded in the examination report, the criteria for a rating higher than 10 percent are not met. In other words, the Veteran's service-connected disability is not productive of such functional impairment as to more nearly approximate the criteria for a 20 percent or higher rating than it does the 10 percent rating currently assigned. In sum, the criteria for a rating in excess of 10 percent for the service-connected lumbar spine disability are not met and are not more nearly approximated than those for the current 10 percent rating. As such, the Board concludes that the preponderance of the evidence is against the claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Service Connection Claims VA law provides that, for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, or other than a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation, except if the disability is a result of the appellant's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C.A. §§ 1110, 1131 (West 2014). Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303 (a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310 (a),(b); Wallin v. West, 11 Vet. App. 509, 512 (1998). For specific enumerated diseases designated as "chronic," there is a presumption that such chronic disease was incurred in or aggravated by service even though there is no evidence of such chronic disease during the period of service. This presumption applies to veterans who served 90 days or more during a period of war or after December 31, 1946. Arthritis is included among the enumerated chronic diseases. However, in order for the presumption to attach, the disease must have become manifest to a degree of 10 percent or more within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), (3); 3.309(a). Presumptive service connection for the specified chronic diseases may alternatively be established by way of continuity of symptomatology under 38 C.F.R. § 3.303(b). However, the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Right Knee Disability The Veteran contends service connection for a right knee disability, but his description as to causation is vague. On his May 2010 application for benefits, he states that his right knee disability began in 2003; however, during his hearing he claims it started during a training exercise while in service. The Veteran also appears to imply that his knee condition is related to his service-connected back disability. Service treatment records reveal no complaints, findings, or diagnoses of a right knee disability. No knee disabilities were documented upon entry into service, and the Veteran's separation report shows a normal evaluation of the lower extremities. The Veteran reports to have received right knee surgery sometimes in the 1970's, although the record contains no documentation of any such surgery. He also reports to a total right knee replacement in September 2011, which is indeed documented within the record. His extensive VA medical records also indicate that the Veteran currently suffers from osteoarthritis of his right knee. Careful review of the record reveals that the Veteran's lay assertions are the only evidence of a relationship between his right knee disability and service. Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr, 21 Vet. App. at 308-09. A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n.4 ('sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer'); 38 C.F.R. § 3.159(a)(2). Here, the Veteran is indeed competent to report symptoms of his right knee disability as he perceives them; however, a diagnosis and etiological opinion require specialized medical training and knowledge. It is not a matter of which is capable of lay observation. Accordingly, the Veteran's lay statements are not competent evidence of his right knee disability's etiological relationship to service. As alluded to above, VA afforded the Veteran a comprehensive medical examination of his right knee and back in August 2014. After examining both parts of the Veteran's body, the physician concluded that the Veteran's knee disability was unrelated to his service-connected back disability. The rationale provided was that the two disabled areas are distinct and separate. This VA examination included a thorough summary and review of the Veteran's medical history, including his service treatment records, and sufficient clinical and diagnostic findings for purposes of determining the nature and etiology of the Veteran's disability. Therefore, the Board finds the opinion to carry great weight. As noted previously, the Veteran's extensive medical record documents that he has arthritis of the right knee. While arthritis is indeed considered chronic under 38 C.F.R. § 3.309(a), presumption to service connection is inapplicable here. The earliest clinical evidence of such a disability is decades after service, and therefore well beyond the presumptive period. The Board finds that a preponderance of evidence is against the Veteran's claim for service connection on a direct, secondary, and presumptive basis. Bilateral Hip Disability The Veteran contends that his bilateral hip disability is related to his service-connected back injury. Service treatment records reveal no complaints, findings, or diagnoses of a hip disability. No hip disabilities were documented upon entry into service, and the Veteran's separation report shows a normal evaluation of the lower extremities. The Veteran's extensive post-service medical records reveal that the Veteran currently suffers from bilateral hip osteoarthritis. The first documented record of such a disability post-service, is decades after separation. While the Veteran argues a relationship between his low back disability and the bilateral hip disability, VA medical records note that in fact, there actually may be a possible relationship between the hip disability and right knee disability. There is no medical evidence supporting the Veteran's contention, however. The only evidence of record relating the Veteran's hip disability with service are the Veteran's own lay statements. The Veteran is indeed competent to report symptoms of his bilateral hip disability as he perceives them; however, a diagnosis and etiological opinion in regard to the disability, requires specialized medical training and knowledge. It is not a matter of which is capable of lay observation. Accordingly, the Veteran's lay statements are not competent evidence of his right bilateral hip disability's etiological relationship to service. The Board notes that the Veteran has not been provided a VA examination in regards to his bilateral hip disability. However, a VA examination is not needed in every case. In McLendon v. Nicholson the Court held that the Secretary must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. Id. at 83. In this case, there is no competent and credible medical evidence of record that relates the disability to service. The only evidence of record are the general lay statements of the Veteran implying a relationship with the service-connected low back disability, which do not meet the low threshold of an indication that the claimed disability is due to service. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (distinguishing cases where only a conclusory generalized statement is provided by the veteran and rejecting the theory that medical examinations are to be routinely and virtually automatically provided to all veterans in disability cases involving nexus issues). Therefore, the Board finds that a remand to obtain a VA examination for this issue is unnecessary. The Board finds that a preponderance of evidence is against the Veteran's claim for service connection on a direct, secondary, and presumptive basis. Left Foot Disability The Veteran claims that he suffers from a left foot disability related to a documented in-service injury. Service treatment records indicate that the Veteran was seen at sick-call in September 1960, for a blister of the left foot. At the time, the Veteran was instructed to lower his shoe chit to treat and prevent the injury from recurring. There was not record of any recurrence in service, and the first documented complaint of a current foot disability post-service was decades after separation. The Veteran was afforded a VA examination in December 2011, where he complained of pain in his achilles tendon. The examiner diagnosed the Veteran with achilles tendonitis and concluded that his documented blister in September 1960 is unrelated to the Veteran's current condition impacting his tendon. This VA examination included a thorough summary and review of the Veteran's medical history, including his service treatment records, and sufficient clinical and diagnostic findings for purposes of determining the nature and etiology of the Veteran's disability. Therefore, the Board finds the opinion to carry great weight. The Board reiterates that the only evidence of record relating the Veteran's left foot disability with service are the Veteran's own bare assertions. The Veteran has not explained, either in writing or at his Board hearing, what the relationship is between his currently diagnosed Achilles tendinitis and the left foot blister he had in service. The only competent and credible evidence addressing the issue is the December 2011 VA examination and opinion, which found no etiological relationship. Therefore, the preponderance of the evidence is against the Veteran's claim for service connection for a left foot disability. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). ORDER Entitlement to a disability rating in excess of 10 percent for low back disability is denied. Entitlement to service connection for right knee disability, to include as secondary to service-connected lumbar spine disability, is denied. Entitlement to service connection for a bilateral hip disability, to include as secondary to service-connected lumbar spine disability, is denied. Entitlement to service connection for a left foot disability is denied. REMAND The Veteran testified at his May 2017, Board hearing that his hearing loss has worsened in both ears since his most recent VA examination for disability benefits was conducted in August 2010. For the purpose of getting hearing aids, an additional audiological examination was conducted in April 2017. It was noted in the accompanying report that since his last audiological examination in 2010, his right ear had additional hearing loss between 10-15 decibels, while his left ear had additional hearing loss between 10-20 decibels. The Board regrets that this recent examination report does not contain enough detail to provide an accurate understanding of the Veteran's hearing disability. When a claimant alleges that his or her service-connected disability has worsened since the last examination, a new examination may be required to evaluate the current degree of impairment. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The also Board notes that the issue of entitlement to a TIDU is inextricably intertwined with the remanded claim. See Harris v Derwznski, 1 Vet App 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Therefore, the Board cannot decide the issue of entitlement to TDIU until development of the claim for entitlement of a compensable disability rating for bilateral hearing loss is complete. As the Board finds the evidence of record, including the assertions of the Veteran, to be competent and credible evidence, the issue of entitlement of a compensable disability rating for bilateral hearing loss is REMANDED for the following action: 1. Request that the Veteran identify any outstanding VA or private medical records. Take appropriate efforts to obtain any records identified. 2. Attempt to obtain any audiometric testing results associated with the April 2017 audiological assessment associated with obtaining or adjusting hearing aids. 3. Schedule an appropriate VA examination to determine the current severity of his service-connected hearing loss. 4. Readjudicate the claims of entitlement to a compensable disability rating for bilateral hearing loss and TDIU. If either benefit sought on appeal is not granted, the Veteran and his representative should be provided a Supplemental Statement of the Case and an appropriate time period for response. The case should then be returned to the Board for further consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs