Citation Nr: 1751283 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 09-36 293 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a right hip disability. 3. Entitlement to service connection for a right ankle disability. 4. Entitlement to service connection for a skin disability, to include psoriasis and flat warts. 5. Entitlement to service connection for tinea pedis. 6. Entitlement to service connection for diabetes mellitus. 7. Entitlement to service connection for peripheral neuropathy of the upper extremities, to include as secondary to diabetes mellitus. 8. Entitlement to service connection for peripheral neuropathy of the lower extremities, to include as secondary to diabetes mellitus. 9. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus. 10. Entitlement to service connection for polyuria, to include as secondary to diabetes mellitus. 11. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus. 12. Entitlement to service connection for bilateral hearing loss. 13. Entitlement to a rating in excess of 50 percent for a psychiatric disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran had active service from June 1967 to February 1969. This case comes to the Board of Veterans' Appeals (Board) from August 2008 and December 2008 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In January 2014, the Veteran testified before the undersigned Veterans Law Judge during a Board hearing at the RO. A transcript of the hearing has been associated with the claims file. In December 2015, the Board remanded the claims for additional development. While on remand, service connection for irritable bowel syndrome, also claimed as spastic colon, was granted by the RO in a February 2017 decision, representing a full grant of that benefit sought. As such, the issue of entitlement to service connection for irritable bowel syndrome, also claimed as spastic colon, is no longer before the Board. The issues of entitlement to service connection for hypertension, polyuria, and bilateral hearing loss are REMANDED to the Agency of Original Jurisdiction. FINDINGS OF FACT 1. The preponderance of the evidence weighs against associating any currently diagnosed low back disability with any incident of service. 2. The preponderance of the evidence weighs against associating any currently diagnosed right hip disability with any incident of service. 3. The preponderance of the evidence weighs against associating any currently diagnosed right ankle disability with any incident of service. 4. The preponderance of the evidence weighs against associating any currently diagnosed skin disability with any incident of service. 5. The Veteran does not have a current diagnosis of tinea pedis. 6. The Veteran does not have a confirmed diagnosis of diabetes mellitus. 7. The Veteran does not have a confirmed diagnosis of peripheral neuropathy of the bilateral upper extremities. 8. The Veteran does not have a confirmed diagnosis of peripheral neuropathy of the bilateral lower extremities. 9. Resolving all reasonable doubt in favor of the Veteran, the evidence supports a finding that the Veteran has erectile dysfunction related to a service-connected psychiatric disability. 10. Throughout the period on appeal, the evidence of record shows that the Veteran's psychiatric disorder has been productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: depressed mood, anxiety, and chronic sleep impairment, occasional panic attacks, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2016). 2. The criteria for entitlement to service connection for a right hip disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2016). 3. The criteria for entitlement to service connection for a right ankle disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2016). 4. The criteria for entitlement to service connection for a skin disability, to include psoriasis and flat warts, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2017). 5. The criteria for entitlement to service connection for tinea pedis have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2017). 6. The criteria for entitlement to service connection for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2017). 7. The criteria for entitlement to service connection for peripheral neuropathy of the upper extremities have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2017). 8. The criteria for entitlement to service connection for peripheral neuropathy of the lower extremities have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2017). 9. The criteria for service connection for erectile dysfunction have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2017). 10. The criteria for a rating in excess of 50 percent for a psychiatric disorder have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9421 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION While the Board must provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on behalf of the Veteran. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence of record. The Veteran should not assume that the Board has overlooked evidence that is not explicitly discussed. Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not given to each piece of evidence in the record. Every item of evidence does not have the same probative value. When the evidence is assembled, the Board 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 a claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Duties to Notify and Assist VA has a duty to notify a Veteran of the information and evidence necessary to substantiate a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2017). VA also has a duty to assist Veterans in the development of claims. 38 U.S.C.A. §§ 5103, 5103A (West 2014). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2017); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will to provide; and (3) that the claimant is expected to provide. The notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements apply to all five elements of a service-connection claim, to include (1) Veteran status; (2) existence of a disability; (3) a connection between service and the disability; (4) degree of disability; and (5) effective date of the disability. The notice should include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Correspondence dated in April 2008 and November 2008 provided all necessary notification to the Veteran. VA has done everything reasonably possible to assist the Veteran with respect to the claims for benefits. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c) (2017). The service medical records have been associated with the claims file. All identified and available treatment records have been secured, which includes VA examinations and VA medical records. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). When VA provides an examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has been provided with VA examinations, most recently in January 2016. The examiners reviewed the claims file and past medical history, and made appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board concludes that the VA examination reports are adequate for the purpose of making a decision. 38 C.F.R. § 4.2 (2015); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board additionally notes that on remand, additional treatment records were obtained and associated with the record. Additionally, new VA examinations were conducted, and the claims were readjudicated. Therefore, the Board finds that there has been substantial compliance with the remand instructions. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). The Board is satisfied that all relevant facts have been adequately developed to the extent possible and that no further assistance is required to comply with the duty to assist. Accordingly, the Board will proceed with a decision. Service Connection Service connection may be granted for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2017). In order to establish service connection for a claimed disability, there must be (1) medical 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, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be granted for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 2014); 38 C.F.R. § 3.303(d) (2017); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist 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. Arthritis is among the chronic diseases listed in 38 C.F.R. § 3.309(a), and service connection for arthritis may be established based on a continuity of symptomatology. Furthermore, service incurrence will be presumed for certain chronic diseases, including arthritis, if manifest to a compensable degree within the year after active service. 38 U.S.C.A. § 1112 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2017). A disability that is proximately due to or the result of a service connected disease or injury shall be service connected. When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. 38 C.F.R. § 3.310(a) (2016). Secondary service connection may also be established for a non-service connected disability, which is aggravated by a service-connected disability. In such an instance, the Veteran is compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 7 Vet. App. 439 (1995). Low Back The Veteran claims he injured his low back in service when he was thrown into shallow water and landed on his left side. He further claims he repeatedly injured his low back in service after the initial injury while working on helicopters and diving into bunkers and trenches during mortar and rocket attacks. Service treatment records show that in July 1968, the Veteran developed pain and swelling above the left iliac crest after having been thrown into shallow water and landing on his left side. X-rays showed no fracture or deformity, and he was diagnosed with a hematoma of the abdominal wall. The February 1969 service separation examination report found that the Veteran had a normal spine. The Veteran indicated on a corresponding Report of Medical History that he did not have recurrent back pain. On VA examination in February 1970, the Veteran recounted his in-service experience of being thrown in the water while at a party on the beach while on active duty. The Veteran further related that he did not have much trouble with his back. The examiner indicated that the Veteran's musculo-skeletal system was normal. In an October 1970 VA psychiatric examination, the Veteran related that he served 14 months in Vietnam. He stated that when he first arrived in Vietnam, he had a Helicopter maintenance assignment. However, within a few months, he had a change to driving a jeep for the Company Commander. The report further contains the Veteran's account as not having had injuries or other illnesses from his service. The Veteran did state later in the report that his back hurt if he sat for a long time or picked up something heavy. The Veteran recalled that while he was in service, he was at a party at a beach when he was picked up by some other servicemen and thrown into the water. It was further noted that the day after the party, the Veteran attended the medical clinic, and there were negative findings in all regards to any injury. A July 1974 VA hospitalization record contains the Veteran's report of injuring his lower back while on active duty. He currently experienced pain on exertion. A March 1990 VA treatment record contains the Veteran's report of low back pain of two months duration. An X-ray found a slight degree of degenerative disc disease. In April 1990, the Veteran was treated for low back pain. A private X-ray taken in September 1990 found a slight degree of degenerative disc disease. A VA X-ray taken in October 1990 found slight degenerative changes of the lower lumbosacral spine. Narrowing disc spaces at L4-L5 and L5-S1 and anterior spurs at L4 and L5 were shown on an October 1992 X-ray. In December 1999, the Veteran underwent an L4 laminectomy and a right L4-5 discectomy. The Veteran was in an automobile accident in August 2001 and complained of low back pain. An X-ray found moderate to severe degenerative changes, moderate degenerative disc changes, no acute fracture, and evidence for decompressive laminectomy at the L5 level. A February 2003 private hospitalization record shows that the Veteran had an exacerbation of lower back pain secondary to a recent automobile accident. Subsequent treatment records generally show treatment for low back pain. On VA examination in January 2016, the examiner diagnosed degenerative disc disease, intervertebral disc syndrome, and spinal stenosis. The examiner opined that the Veteran's low back disability was less likely than not incurred in or caused by service. The examiner reviewed the service medical records and post-service records and found that the Veteran had no other post-service reports of back pain or documentation to support having a chronic back condition until 1990, 20 years after active duty. The examiner found the Veteran's reports of how his initial claimed injury occurred to be misleading. He noted that in a psychiatric examination in 1970, the Veteran reported being assigned to helicopter maintenance, then driving jeep for the commander. He had 19 months of service and the Veteran stated at the time had no injuries or other illnesses. The examiner noted that the Veteran's current claim form showed a report of injuring his low back while working on helicopters and diving into bunkers and trenches during mortar and rocket attacks. On present examination, the Veteran told the examiner that he hurt his back on three occasions: working on a helicopter, falling out of a helicopter, and being thrown into the water at a beach party. The examiner noted that the Veteran's in-service X-rays following being thrown in the water were normal, and the Veteran stated in the 1970 psychiatric examination that "I've not had much trouble with it." The examiner concluded by noting that the Veteran marked "no" to recurrent back pain at the time of his separation physical. After considering the evidence of record, the Board finds that service connection is not warranted for a low back disability. Arthritis of the lumbar spine was not shown within one year following separation from service. Consequently, presumptive service connection is not warranted. Concerning direct service connection, while the Veteran currently has a low back disability, the most probative evidence of record does not associate any current low back disability with service. In this matter, the Board finds the January 2016 VA examiner's opinion to be the most probative evidence of record. The January 2016 VA examination report outlines the reasons why the examiner felt that the Veteran's current low back disability was less likely to be related to service. The examiner considered the Veteran's self-report, the service medical records, the post-service records, and explained the factors behind the determination that the current low back disability was less likely to be related to service. The Board finds the January 2016 VA examination report to be the most persuasive evidence of record. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. Hayes v. Brown, 5 Vet. App. 60 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Board has considered the various treatment records which recite that the Veteran's low back disability was secondary to an injury that occurred while the Veteran was in Vietnam. However, the examiners who created these records did not have access to the Veteran's service medical records. They did not comment on the service separation report and the Veteran's indication on a Report of Medical History at the conclusion of service that he did not have back trouble of any sort. They also did not comment on the post-service hospitalization records. It appears that those treatment records were based only on the Veteran's self-reported history, and a medical evaluation that is merely a recitation of a Veteran's self-reported and unsubstantiated history has no probative value. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999); Swann v. Brown, 5 Vet. App. 229 (1993); Godfrey v. Brown, 8 Vet. App. 113 (1995). The Board finds the January 2016 VA examination and addendum to be of greater probative value due to the specific reasoning cited by the examiner. The examiner also had access to the previous medical reports and stated specific reasons for the findings and rebutting the findings of previous treating professionals. Accordingly, after a careful review of the evidence of record, the Board finds that the preponderance of the evidence is against the claim. The preponderance of the evidence is against a finding of a causal connection between the Veteran's service and the current low back disability. The Board is sympathetic to the Veteran in that it is clear he sincerely believes his current low back disability is directly related to his service. However, the evidence of record does not support that contention. Although the Board is appreciative of the Veteran's faithful and honorable service to our country, because the preponderance of the evidence is against the claim, the claim must be denied. As the preponderance of the evidence is against the claims of entitlement to service connection for low back disability, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right Hip The Veteran claims he injured his right hip in service when he first injured his low back and he has had problems with that hip since service. The service medical records do not show any complaints of a right hip disability. The February 1969 service separation examination report shows that the Veteran had a normal spine and normal lower extremities. The Veteran indicated on a corresponding Report of Medical History that he had swollen or painful joints, but the examiner noted that the complaints were mild and evaluation of the lower extremities was normal. On VA examination in February 1972, the examiner indicated that the Veteran had a normal musculo-skeletal system. A January 1991 VA treatment record shows that the Veteran had a tree fall on his right leg. An X-ray found no evidence of fracture or dislocation. Slight degenerative changes of the right hip joint were seen. A radiology report from October 1999 found mild degenerative changes involving the right hip. On VA examination in January 2016, the examiner diagnosed degenerative arthritis of the right hip. The examiner opined that the Veteran's right hip disability was less likely than not incurred in or caused by service. The examiner noted that on the Veteran's claim form, he stated that he injured his right hip when he first injured his low back on active duty, and he had problems with his right hip since that time. However, the service medical records showed that when the Veteran was thrown into the water and hurt his back while on active duty. He stated that he landed on his left side, not his right. The accident reports did not show that the right hip was injured. The examiner also noted that on present examination, the Veteran denied experiencing right hip pain that was unrelated to back pain. Finally, the examiner stated that degenerative disease was a normal aging process. After considering the evidence of record, the Board finds that service connection is not warranted for a right hip disability. Arthritis of the right hip was not shown within one year following separation from service. Consequently, presumptive service connection is not warranted. Concerning direct service connection, the Veteran has a diagnosis of a current right hip disability. However, the most probative evidence of record does not associate any current right hip disability with service. The Board finds the January 2016 VA examiner's opinion to be the most probative evidence of record. The January 2016 VA examination report outlines the reasons why the examiner felt that the Veteran's current right hip disability was less likely related to his service. The examiner considered the Veteran's self-report, the service medical records, the post-service records, and explained the factors behind the determination that the current right hip disability was less likely related to service. Significantly, the January 2016 VA examiner provided an alternate etiology for the right hip disability. The Board finds the January 2016 VA examination report to be the most persuasive evidence of record. To the extent that the Veteran believes that his right hip disability is related service, the Board notes that the Veteran is competent to provide testimony concerning factual matters of which he has first-hand knowledge and experiences through his senses. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Further, under certain circumstances, lay statements may support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). VA provided the Veteran with an examination based in part on the competency of those observations. Lay persons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, as to the etiology of a right hip disability, the issue of causation of a medical condition is a medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, although the Board has carefully considered the lay contentions of record suggesting that the Veteran's right hip disability is related to service, the Board ultimately assigns the objective medical evidence of record, which weighs against finding a connection between the Veteran's right hip disability and his service, greater probative weight than the lay opinions because of the medical training and knowledge of the examiner. As the preponderance of the evidence is against the claim of entitlement to service connection for a right hip disability, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right Ankle The Veteran claims he injured his right ankle in service and he has had problems with that ankle since service. The service medical records show complaints of a swollen right ankle in March 1968. The February 1969 service separation examination report shows that the Veteran had normal lower extremities. The Veteran complained of swollen or painful joints at the separation examination, but the examiner noted that the complaints were mild and evaluation of the lower extremities was normal. On VA examination in February 1972, the examiner indicated that the Veteran had a normal musculo-skeletal system. An X-ray of the lower part of the right leg taken in August 1974 was normal. Subsequent treatment records do not show ongoing treatment for a right ankle disability. On VA examination in January 2016, the examiner diagnosed degenerative arthritis of the right ankle. The examiner opined that the right ankle degenerative joint disease was less likely to have been incurred in or caused by his service. The examiner noted that the service medical records documented that the Veteran was treated for right ankle swelling on March 1968, but no specific injury was reported as the cause of the swelling. The Veteran did not recall a specific injury to the ankle during the service, but he recalled that it hurt during that time. The examiner noted that on present examination, the left ankle did not deviate significantly from the right ankle, and degenerative joint disease was a common aging process. After considering the evidence of record, the Board finds that service connection is not warranted for a right ankle disability. Arthritis of the right ankle was not shown within one year following separation from service. Consequently, presumptive service connection is not warranted. Concerning direct service connection, the Veteran has a diagnosis of a current right ankle disability. However, the most probative evidence of record does not associate his current right hip disability with his service. In addition, the evidence does not show a continuity of symptomatology as the lower extremities were normal at separation and the next reported complaint of ankle problems was many years after service. Again, the Board finds the January 2016 VA examiner's opinion to be the most probative evidence of record. The January 2016 VA examination report outlines the reasons why the examiner felt that the current right ankle disability was less likely to be related to service. The examiner specifically noted the Veteran's documented in-service treatment for right ankle pain. The examiner considered that treatment in connection with the current findings in explaining the reasoning behind the determination that the current right ankle disability was less likely to be related to service. The January 2016 VA examiner additionally provided an alternate etiology for the right ankle disability as part of the aging process. The Board finds the January 2016 VA examination report to be the most persuasive evidence of record. Although the Board has carefully considered the Veteran's assertions that his current right ankle disability is related to service, the Board ultimately assigns the objective medical evidence of record, which weighs against finding a connection between the Veteran's right ankle disability and his service, greater probative weight than the lay opinions because of the medical knowledge and training of the examiner. The Veteran has not submitted any contrary medical evidence relating any ankle disability to service. As the preponderance of the evidence is against the claims of entitlement to service connection for a right ankle disability, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Skin Disabilities (Claimed as Jungle Rot), to include Dermatitis, Psoriasis, and Tinea Pedis The Veteran claims he has a skin disability that began in service. The service medical records show complaints of a rash on the legs and crotch in December 1967 that was diagnosed as questionable ringworm. In February 1968, the Veteran complained of a rash in the groin and the right leg and athlete's feet, and he was prescribed Tinactin and Benadryl. In March 1968 he complained of a rash and was diagnosed with tinea cruris and prescribed Tinactin. He was seen again later that month and given Tinactin for his feet. He was seen in May 1968 for athlete's foot on the right foot and prescribed Desenex. The Veteran complained of heat rash with itching in July 1968 and was prescribed Benadryl and Kenalog spray. The February 1969 service separation examination report shows that the Veteran had normal skin. He complained of skin diseases and athlete's foot at the separation examination, but other than a scar on the right leg below the knee, evaluation of the skin was normal. On VA examination in February 1972, the examiner indicated that the Veteran had normal skin. In May 1998, the Veteran was treated for tinea corporis. In November 2000, the Veteran was treated for dry skin. A February 2001 treatment record contains a diagnosis of tinea cruris. On VA examination in April 2002, the Veteran complained of skin symptoms affecting his feet, crotch, hands, and elbows. He reported having difficulty with his feet and hands while he was in Vietnam. The examiner observed dryness of the Veteran's hands and elbows. The feet were dry, and there were no signs of ulcerations or crusting. The examiner felt that all of the Veteran's current symptoms most likely represented atopic dermatitis. The examiner did not see anything that he thought was fungus with a possible exception of the right great and small toenails. The examiner explained that atopic dermatitis was generally an inherited disorder, and in many people it was a lifelong problem that tended to wax and wane. Subsequent VA treatment records list dermatitis as a current problem with a diagnosis of dry skin in December 2009 and a referral to dermatology for psoriasis in July 2011. On VA examination in January 2016, diagnoses of psoriasis and flat warts were made. The examiner opined that the Veteran's skin conditions were less likely than not incurred in or caused by service. The examiner explained that the Veteran was diagnosed with psoriasis in 2011, and psoriasis had a genetic predisposition. As psoriasis was genetic, it was not related to the Veteran's service. The examiner specified that the Veteran was given the topical steroid clobetasol for treatment of psoriasis, and hydrocortisone may also be used for treatment of psoriasis. Concerning the flat warts, the examiner specified that was a viral condition caused by Human Papillomavirus. Transmission included skin-to-skin contact. The examiner stated that the flat warts were unrelated to the fungal infections the Veteran experienced during service, and the flat warts were not caused by the fungal infections he experienced during service. Concerning the claimed tinea pedis/cruris, the examiner specified that those were fungal conditions that required an antifungal for treatment. The Veteran did not have any current clinical signs or symptoms of tinea pedis or cruris on examination. After considering the evidence of record, the Board finds that service connection is not warranted for a skin disability, to include dermatitis and psoriasis. The Veteran has a current diagnosis of psoriasis and flat warts. However, the most probative evidence of record does not associate those diagnosed disabilities with service. The Board finds the January 2016 VA examiner's opinion to be the most probative evidence of record. The January 2016 VA examination report outlines the reasons why the examiner felt that the Veteran's current psoriasis and flat warts were less likely to be related to his service. The examiner specifically noted the Veteran's documented in-service treatment for rashes and ringworm. The examiner considered that treatment in connection with the current findings. The January 2016 VA examiner additionally provided greater detail concerning the nature of the diagnosed disabilities in addition to an alternate etiology. The Board finds the January 2016 VA examination report to be the most persuasive evidence of record. Although the Board has carefully considered the Veteran's assertions that his current skin disabilities are related to service, the Board ultimately assigns the objective medical evidence of record, which weighs against finding a connection between the Veteran's diagnosed psoriasis and flat warts and his service, greater probative weight than the lay opinions because of the medical knowledge and training of the examiner. The Veteran has not submitted any contrary medical evidence relating any current skin disability to service. Concerning tinea pedis, the evidence of record does not provide any medical basis for finding that the Veteran is currently diagnosed with tinea pedis. While the service medical records document treatment for ringworm, tinea cruris, and athlete's foot, merely establishing a showing in service is not sufficient to grant service connection because there also has to be chronic residual disability resulting from that inservice condition or injury. Chelte v. Brown, 10 Vet. App. 268 (1997). Under applicable regulation, the term disability means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1 (2015); Hunt v. Derwinski, 1 Vet. App. 292 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board finds that service connection for tinea pedis is not warranted. A specific disability of tinea pedis or athlete's foot has not been identified during or contemporary to the period on appeal by any competent evidence of record. Notably, none of the competent evidence of record demonstrates that the Veteran has a diagnosis of tinea pedis or athlete's foot. Service connection may not be granted for symptoms unaccompanied by a diagnosed disability. Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001); Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). In the absence of a clear diagnosis of a current disability, or any abnormality which is attributable to some identifiable disease or injury during service, an award of service connection is not warranted. The presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). Because there was no actual disability diagnosed at any time since the claim was filed or contemporary to the filing of the claim, and there remains no current evidence of the claimed disability, no valid claim for service connection for tinea pedis or athlete's foot exists. As the preponderance of the evidence is against the claim for service connection for a skin disability and tinea pedis, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Diabetes Mellitus The February 1969 service separation examination report shows that the Veteran had a normal endocrine system. A urinalysis was negative for glucose. The Veteran indicated on a corresponding Report of Medical History that he did not experience sugar in his urine. On VA examination in February 1970, a urinalysis was negative for glucose. On VA examination in March 2010, the examiner specified that the Veteran did not meet the diagnostic criteria for a diagnosis of diabetes by either fasting glucose levels or glucose tolerance test. The examiner opined that the Veteran had impaired glucose tolerance. While earlier VA treatment notes showed that the Veteran had diabetes insipidus, notes through August 2014 indicate that he does not have diabetes. However, a November 2014 private treatment note shows that he has diabetes mellitus. On VA examination in January 2016, the examiner reviewed all of the available records and performed an in-person examination of the Veteran. The examiner specified that there was not an official diagnosis of Diabetes Mellitus Type I or II. The Veteran's A1C on examination was 5.8 percent. The examiner noted that the Veteran stated that when he was hospitalized, he was given insulin shots. In reviewing the Veteran's in-patient records, the examiner noted that the Veteran was treated with steroids for COPD. The examiner stated that steroids will cause blood sugars to elevate outside of normal range, which necessitated the need for insulin management. The examiner specified that the Veteran's blood sugar elevation was a result of prednisone, not diabetes mellitus. The examiner concluded that the Veteran did not meet the criteria for a diagnosis of diabetes mellitus. The Board finds that service connection for diabetes mellitus is not warranted. While the Veteran has had elevated blood sugar readings, the preponderance of the evidence does not show that these readings have resulted in an actual confirmed diagnosis of diabetes mellitus. The January 2016 examiner explained specifically why a diagnosis of diabetes mellitus was not warranted and attributed the elevated blood sugar readings to a different, and temporary causation. In this matter, the Board acknowledges the private treatment records which show treatment for diabetes. However, the Board finds that the most probative evidence in this case comes from the VA examiner who reviewed the file in January 2016. That examiner specifically reviewed the treatment records and explained why the Veteran did not meet the diagnostic criteria for a diagnosis of diabetes mellitus. The examiner referenced the applicable treatment records and provided detailed reasoning for the opinions. For these reasons, the Board finds that the opinion of the VA examiner outweighs the other evidence of record. The examiner specifically considered the previous evidence of record and provided a sound basis to refute those opinions that suggested that the Veteran did have diabetes. The Veteran has had elevated blood sugar. However, as explained by the VA examiner, the elevated readings have not been high enough and consistent enough to meet the diagnostic criteria for a confirmed diagnosis of diabetes mellitus. Additionally, the examiner provided an alternate explanation for the elevated readings. Therefore, the requirement that there be current disability has not been met. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board finds that service connection is not warranted for diabetes mellitus because the preponderance of the evidence is against a finding that a diagnosis of diabetes mellitus is warranted. Although the Board is sympathetic to the Veteran's claim, absent a confirmed diagnosis, service connection cannot be granted. The Board finds that the preponderance of the evidence is against a finding that a diagnosis of diabetes mellitus is warranted. Therefore, the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2017). Peripheral Neuropathy of All Extremities An August 1968 service treatment record contains the Veteran's complaints of a numb right foot. On VA examination in February 1972, the examiner indicated that the Veteran had a normal neurological system. A December 1999 private hospitalization record contains a diagnosis of right L5 radiculopathy secondary to L4-5 herniated disc. A September 2000 private treatment record shows that the Veteran denied having any neck or arm pain suggestive of cervical radiculopathy. The examiner also stated that the Veteran's lumbar surgery successfully resolved the prior lumbar radicular type symptoms. An April 2003 VA treatment record shows that the veteran had no focal neurologic deficits. Strength and sensation in the upper and lower extremities were intact. A nerve conduction study performed in May 2003 found that the Veteran's right median motor latency was borderline normal, and the remainder of the nerve conduction study of the right upper extremity was normal. Nerve conduction study of the right lower extremity was normal. Needle EMG of the right upper and lower extremities was normal. The assessment was mild right carpal tunnel syndrome. A private examination conducted in October 2004 concluded in a diagnosis of chronic cervical and lumbosacral strain without evidence of radiculopathy. On VA examination in March 2010, the examiner noted that the Veteran reported problems with both hands and both feet for the prior 35 years or longer. The Veteran stated that he had numbness that came and went of all four extremities. After performing an examination, the examiner found that there was subjective neuropathy of the bilateral upper and lower extremities with a normal physical examination. The Veteran has claimed that he has peripheral neuropathy of all of his extremities secondary to diabetes mellitus. However, as service connection has not been granted for diabetes, service connection for peripheral neuropathy cannot be granted as secondary to diabetes mellitus. The Board also finds that service connection for peripheral neuropathy of the bilateral upper and lower extremities is not warranted on a direct basis. While the Veteran has been found to have subjective numbness and tingling of the extremities, the preponderance of the evidence does not show that those readings have resulted in an actual current confirmed diagnosis of peripheral neuropathy. In this matter, the Board acknowledges the treatment records which show treatment for radiculopathy symptoms and carpal tunnel syndrome in the past. However, those records also suggest that the underlying disabilities resolved before the present claim for service connection was filed in November 2008, as the treatment records from November 2008 through the present are negative for a confirmed diagnosis of a neurological disability of either of the upper or lower extremities. The Board finds that the most probative evidence in this case comes from the VA examiner who examined the Veteran in January 2016. That examiner reported on the examination findings and acknowledged the Veteran's reported subjective symptoms, but objectively, the examination did not support a diagnosis of peripheral neuropathy of any of the extremities. The examiner had the medical training and expertise to make that determination. For these reasons, the Board finds that the opinion of the VA examiner outweighs the other evidence of record. The Veteran experiences numbness and tingling in his extremities. However, as explained by the VA examiner, those symptoms are subjective. Objective testing shows that the Veteran does not meet the diagnostic criteria for a confirmed diagnosis of peripheral neuropathy. Therefore, the requirement that there be current disability has not been met. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board finds that service connection is not warranted for peripheral neuropathy of the bilateral upper and lower extremities because there is no confirmed diagnosis of peripheral neuropathy current to the present appeal. Any radiculopathy is shown to be related to a nonservice-connected back disability. Furthermore, diabetes mellitus has not been service-connected, so a secondary claim as related to diabetes must fail. In addition, the competent evidence of record does not support a finding that it is at least as likely as not that any subjective peripheral neuropathy is related to service. Although the Board is sympathetic to the Veteran's claim, absent a confirmed diagnosis, service connection cannot be granted. The preponderance of the evidence is against a finding that a diagnosis of peripheral neuropathy is warranted. Therefore, the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2017). Erectile Dysfunction The February 1969 service separation examination report shows that the Veteran had a normal genito-urinary system. A July 1974 VA hospitalization record contains the Veteran's report that he could not maintain an erection. On VA examination in March 2010, the Veteran reported that he had problems obtaining an erection since about 1969. The examiner opined that the Veteran's erectile dysfunction was most likely due to his psychological condition. The Veteran has claimed that he has erectile dysfunction secondary to diabetes mellitus. As service connection has not been granted for diabetes, service connection for erectile dysfunction cannot be granted as secondary to diabetes mellitus. However, the March 2010 VA examiner opined that erectile dysfunction was most likely due to his psychological condition, which is service-connected. Significantly, no other evidence contradicts the March 2010 VA examiner's opinion. As the medical evidence of record shows that the Veteran's erectile dysfunction is due to or the result of his service-connected psychiatric disability, service connection for erectile dysfunction is granted as secondary to a service-connected psychiatric disability. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2017). Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(a), 4.1 (2017). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran is service-connected for a psychiatric disabilities and assigned a 50 percent rating. Psychiatric disabilities other than eating disorders are rated pursuant to a General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130 (2017). Under the General Rating Formula, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affected the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2017). The symptoms listed in the rating formula are only examples, and evidence of those specific symptoms is not required to show that the Veteran is totally disabled. In rating a mental disability, VA is required to consider all symptoms that affect social and occupational functioning, and not limit consideration to those symptoms listed in the rating formula. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary consideration is whether the manifestations of the service-connected psychiatric disability result in a level of social and occupational impairment, regardless of whether the Veteran demonstrates the symptoms listed in the rating formula. When rating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (2017). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale grading the psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness. Carpenter v. Brown, 8 Vet. App. 240 (1995); American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV). According to the DSM-IV, GAF scores ranging between 61 to 70 indicate some mild symptoms [e.g., depressed mood and mild insomnia] or some difficulty in social, occupational, or school functioning [e.g., occasional truancy, or theft within the household], but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 indicate more moderate symptoms [e.g., flat affect and circumstantial speech, occasional panic attacks] or moderate difficulty in social, occupational, or school functioning [e.g., few friends, conflicts with peers or co- workers]. GAF scores ranging from 41 to 50 indicate serious symptoms [e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting] or any serious impairment in social, occupational or school functioning [e.g., no friends, unable to keep a job]. GAF Scores ranging from 31 to 40 indicate some impairment in reality testing or communication [e.g., speech is at times illogical, obscure, or irrelevant] or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood [e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school]. While the rating schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability ratings based solely on GAF scores. 38 C.F.R. § 4.130 (2017). Psychiatric Disability Service connection for somatization disorder and major depressive disorder was granted in an April 1970 rating decision. A 10 percent disability rating was granted, effective February 5, 1969. Later, an increased 50 percent rating was granted, effective September 8, 2000. The present claim for a higher rating was submitted in December 2007. On VA examination in May 2008, the examiner noted that the Veteran was treated with an antidepressant. The Veteran felt depressed and had low energy. The examiner found the Veteran to be clean and casually dressed. His attitude was cooperative, and his affect was constricted. He was oriented to person, time, and place. Thought process and content was unremarkable. No hallucinations or delusions were present. The Veteran would count his steps, posts, guard rails, tiles, and concrete blocks. He did not have panic attacks. While the Veteran did not have homicidal thoughts, he had suicidal thoughts with no intent on following through. Remote, recent, and immediate memory were normal. A GAF score of 55 was assigned. The examiner concluded that the Veteran's psychiatric symptoms did not result in total occupational and social impairment, or deficiencies in judgment, thinking, family relations, work, mood, or school. The examiner felt that there was reduced reliability and productivity due to the mental disorder symptoms. VA treatment records dated September 2009 and December 2009 show that the Veteran experienced anxiety and depression. The Veteran complained of decreased memory and concentration and sleep disruption. He denied experiencing suicidal or homicidal ideation. A GAF score of 55 was assigned. On VA examination in March 2010, the Veteran stated that he had trouble sleeping. He experienced bad memories. He had been married to his wife since 1969. He had a few friends. The examiner found the Veteran to be clean and casually dressed. His speech was unremarkable. He had a cooperative attitude but a depressed mood. Thought process and content were unremarkable. No delusions or hallucinations were present. No panic attacks were reported. While the Veteran had some suicidal thoughts, he denied experiencing suicidal ideation. Remote, recent, and immediate memory were normal. Psychological testing was performed. However, the examiner felt that the results were probably invalid as the Veteran's scores indicated more psychopathology than the Veteran could describe during clinical interview when asked open ended questions. The examiner noted that the Veteran stopped working due to back problems and COPD. A GAF score of 52 was given. A VA psychiatric follow-up note from March 2010 shows that the Veteran had decreased memory and concentration, irritability, worry, and fatigue. He experienced occasional nightmares and flashbacks. The Veteran made good eye contact and was alert and oriented. His affect was appropriate. There were no audio or visual hallucinations, paranoia, or delusions. No suicidal or homicidal ideation was present. A private psychiatric assessment completed in June 2010 indicates that the Veteran was appropriately groomed and casually dressed. The Veteran's train of thought was coherent with no disturbances of logic. The Veteran remarked that he was usually depressed. He felt nervous most of the time. He experienced unhappiness and a lack of joy. There were no psychotic distortions or hallucinations. The Veteran reported that he slept approximately four hours nightly. He experienced panic attacks approximately every two months. He had severe nightmares. The Veteran later claimed that he experienced hallucinations approximately every six months. The examiner clarified that what the Veteran described as hallucinations were related to his nightmares. The examiner assigned a GAF score of 31. On VA examination in September 2011, the examiner felt that the Veteran's psychiatric symptoms were best summarized as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The examiner felt that any occupational impairments were mild and transient and more likely due to nonservice-connected medical conditions than to the somatization disorder. The Veteran was married and had a supportive relationship with his adult children. He was not active in church. The Veteran medically retired in 1999 after back surgery. The Veteran had a depressed mood and chronic sleep impairment. He would check his doors and windows repeatedly even when he knows he has already checked them. The examiner specified that psychiatric testing suggested that the Veteran was overreporting his symptoms. The examiner opined that the Veteran's psychiatric symptoms did not prevent all types of gainful employment. A GAF score of 62 was assigned. Treatment record from September 2012, November 2012, March 2013, May 2013, October 2013, January 2014, May 2014, show that the Veteran experienced anxiety and sleeplessness. There was no suicidal or homicidal ideation. The Veteran was alert and oriented to person, place, and time. Cognition was intact. Thought process revealed no flight of ideas or loosening of association. No delusions or paranoia were present. There were no visual or auditory hallucinations. Insight was low to fair. A GAF score of 55 was assigned. A private psychiatric assessment completed in January 2013 shows that the Veteran was alert, fully oriented, and adequately groomed. His expressions and mannerisms were appropriate. The Veteran volunteered information and was cooperative. His speech was relevant and of an appropriate rate and volume. Thought processes were spontaneous, logical, and coherent. There was also noticeable circumstantiality, suspiciousness, and paranoia. No hallucinations or delusions were noted. The Veteran had a flat affect. He was moderately anxious. Memory processes were intact. The Veteran denied suicidal and homicidal ideation. Insight and judgment were considered poor. The examiner gave diagnoses of posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, and pain disorder. The examiner found that the Veteran was totally occupationally and socially impaired and unemployable. The private examiner assigned a GAF score of 42. On VA examination in January 2016, the examiner opined that the symptoms manifest by the Veteran's psychiatric disability were best summarized as occupational and social impairment with reduced reliability and productivity. The Veteran had lived with his current wife since May 1969. They were living with their daughter. The Veteran did little socially. He spent most of his time sitting around the house. He had been prescribed Paroxetine. The Veteran displayed a depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The Veteran denied current suicidal or homicidal ideation. The Board finds that the medical evidence, combined with the Veteran's subjective reports of his symptoms, indicates that the psychiatric disability was productive of not more than occupational and social impairment with reduced reliability and productivity due to such symptoms as depressed mood, anxiety, chronic sleep impairment, occasional panic attacks, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships throughout the period of appeal. Therefore, the Board finds the Veteran's symptoms of a psychiatric disability warrant no more than a 50 percent rating throughout the period of appeal. 38 C.F.R. § 4.130, Diagnostic Code 9421 (2017). The Board finds that the preponderance of the evidence is against the assignment of a 70 or 100 percent rating at any time during the appeal because the evidence is against a finding of total occupational and social impairment or occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood or total social and occupational impairment. The evidence indicates that the Veteran maintained a good relationship with his spouse; additionally, he has maintained contact with relatives. Moreover, the September 2011 VA examiner determined that the Veteran only had occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, a finding consistent with a 10 percent rating, a lower rating than the 50 percent rating currently assigned. That finding does not show total occupation or social impairment or deficiencies in most areas. The May 2008 and January 2016 VA examiners determined that the Veteran had occupational and social impairment with reduced reliability and productivity, a finding consistent with than the 50 percent rating currently assigned. That finding does not show total occupation or social impairment or deficiencies in most areas. The Board has carefully considered the January 2013 private report in which the examiner concluded that that the Veteran was totally occupationally and socially impaired and unemployable. However, that examiner's report does not appear to support the given conclusion. The examiner found the Veteran to be suspicious and anxious, but only moderately so. The examiner found the Veteran's speech to be logical. While the Veteran's judgment was deemed poor, the Veteran was still able to function independently. The symptoms that the examiner recorded appear to support the assignment of a 50 percent disability rating, and no higher, despite the finding that the Veteran was unemployable. There is no indication that the Veteran has been violent, and his panic does not appear to prevent functioning independently. While the Veteran occasionally had thoughts of suicide, at no time has the Veteran displayed actual suicidal or homicidal ideation. Therefore, the Board finds that the evidence indicates that the Veteran's disability more closely approximates occupational and social impairment with reduced reliability and productivity. Therefore, the Veteran's psychiatric disability warrants no more than a 50 percent rating throughout the period of appeal. The Board has considered that the June 2010 private examiner assigned the Veteran a GAF score of 31, and the January 2013 private examiner assigned the Veteran a GAF score of 42. However, the symptoms recorded in the reports to not appear to correlate to the GAF scores assigned. As reviewed above, the symptoms recorded by both examiners are indicative of more moderate scores than the GAF scores they actually assigned. Additionally, throughout the time period on appeal, the GAF scores assigned by the VA treatment providers have been more indicative of the actual symptoms recorded. These symptoms are representative of more moderate symptoms or moderate difficulty in social, occupational, or school functioning, also supporting a 50 percent rating. The GAF scores assigned by the VA treatment providers have ranged from 52 to 62, representing moderate symptoms. The Board has considered the Veteran's and spouse's statements regarding the severity of the psychiatric symptoms. The Veteran and spouse are competent to report the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a) (West 2014); 38 C.F.R. § 3.303(a) (2017); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Ultimately, however, the opinions and observations of the Veteran and spouse do not meet the burden for a higher rating imposed by the rating criteria under 38 C.F.R. § 4.130 with respect to determining the severity of his service-connected psychiatric disability. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a higher rating and the claim for increase must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015). Other Considerations Ordinarily, VA's Rating Schedule will apply unless there are exceptional or unusual factors which would make application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57 (1993). An extraschedular rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would make impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2017). There is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. Second, if the schedular rating does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as governing norms. Third, if the rating schedule is inadequate to rate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet App 111 (2008). The Board finds that the evidence in this case does not show an exceptional disability picture and the available schedular rating for the service-connected psychiatric disorder at issue is adequate. There is no allegation or evidence of exceptional factors in this appeal with regard to the service-connected psychiatric disorder. All the symptoms experienced by the Veteran are contemplated or approximated by the appropriate diagnostic criteria which rate the disability based on occupational and social impairment due to all psychiatric symptoms. Therefore, the Board concludes that the schedular criteria reasonably describe the Veteran's disability picture. The Board finds nothing exceptional or unusual about the Veteran's disability because the rating criteria contemplate his symptomatology. The evidence does not support a finding of frequent hospitalization or marked interference with employment due to the psychiatric disability. Thun v. Peake, 22 Vet App 111 (2008). ORDER Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a right hip disability is denied. Entitlement to service connection for a right ankle disability is denied. Entitlement to service connection for a skin disability, to include psoriasis and flat warts, is denied. Entitlement to service connection for tinea pedis is denied. Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for peripheral neuropathy of the upper extremities, to include as secondary to diabetes mellitus, is denied. Entitlement to service connection for peripheral neuropathy of the lower extremities, to include as secondary to diabetes mellitus, is denied. Entitlement to service connection for erectile dysfunction is granted. Entitlement to a rating in excess of 50 percent for a psychiatric disability is denied. REMAND The Veteran has claimed that he has hypertension and polyuria secondary to diabetes mellitus. However, as service connection has not been granted for diabetes, service connection for hypertension and polyuria cannot be granted as secondary to diabetes mellitus. However, that does not foreclose the possibility that the Veteran's claimed hypertension and polyuria might be directly related to active service. On VA examination in March 2010, the Veteran reported that he experienced a weak or intermittent urine stream with hesitancy and dribbling. The examiner did not specifically address the Veteran's reported urinary symptoms. Concerning hypertension, the examiner found that the date of onset of the Veteran's hypertension was unclear. A diagnosis of hypertension was given, but no etiology opinion was offered by the examiner. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). On remand, the Veteran should be schedule for a VA examination that addresses his urinary symptoms and clarifies the etiology of diagnosed hypertension. The Veteran claims that his hearing loss is due to noise exposure in service while serving as a helicopter crew chief. On the December 2007 claim, the Veteran stated that he had hearing loss since service. The Veteran's service separation form indicates that he served in an aviation battalion. Therefore, the Board finds his statements credible regarding noise exposure in service from helicopters. The Veteran underwent VA audiology examination in February 2016. The examiner opined that the Veteran's demonstrated bilateral hearing loss was less likely as not caused by or a result of his military service. The audiologist noted that no significant or permanent threshold shifts occurred from 1967 to 1969, and the audiograms appeared to be reliable. The examiner specified that noise-induced hearing loss does not have a delayed onset, and if service caused hearing loss, it would be apparent in the separation audiogram. The examiner stated that hearing loss would be necessary at the time of separation to establish a direct service connection no matter how erroneous that would appear to the lay person. The Board finds the February 2016 examination report to be inadequate for adjudicative purposes. The Board notes a series of papers by Sharon Kujawa at the Department of Audiology of the Massachusetts Eye and Ear Infirmary, which shows that even in the presence of a "fully" recovered temporary threshold shift (TTS), hair cells are damaged. That study indicates that while people have a finite number of hair cells at any given frequency only a portion of those cells are needed for what we measure as normal hearing, and the remainder could be considered a protective mechanism. That study also suggests that as people age, those hair cells are damaged, and if the redundant cells are not there, the individual experiences a greater hearing loss. The February 2016 examiner did not address those research papers in the report. Therefore, the Board finds that a medical opinion from an otolaryngologist is necessary prior to the final adjudication of this matter. Accordingly, the case is REMANDED for the following action: 1. Obtain all VA treatment records not already associated with the claims file. 2. Then, schedule the Veteran for a VA examination to consider hypertension and symptoms of polyuria. The examiner must review the claims file and the prior examination reports and should note that review in the report. The examiner should address whether a diagnosis of polyuria is appropriate. The examiner should clarify the date of onset of hypertension. Based on the examination, and review of the claims file and prior examination reports, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that polyuria or hypertension was incurred in or are otherwise related to active service. The examiner should specifically note that the absence of in-service evidence of symptoms is not always fatal to a service connection claim and should consider the Veteran's reports and lay statements. If there is another likely etiology for the Veteran's polyuria or hypertension, that should be stated. 3. Then, schedule the Veteran for a VA examination for an opinion on whether any hearing loss diagnosis is as likely as not (50 percent or greater probability) related to noise exposure in service. The examination should be conducted by an otolaryngologist. The Veteran was exposed to loud noise during service. A hearing test and the Maryland CNC word recognition test must be conducted. The examiner must review the claims file and should note that review in the report. The Board notes that the Veteran was not diagnosed with hearing loss at separation or during service, but that is not dispositive on the issue of whether current hearing loss is related to acoustic trauma in service. The examiner is asked to provide comment on the impact on the opinion, if any, of the line of research conducted by Dr. Sharon G. Kujawa, including the following: (a) "Acceleration of Age-Related Hearing loss by Early Noise Exposure: Evidence of a Misspent Youth" by S. Kujawa, M.D., and M. C. Liberman (2006). - J Neurosci. 2006 Feb 15; 26(7): 2115-2123. (b) Kujawa SG, Liberman MC (2009) Adding insult to injury: cochlear nerve degeneration after "temporary" noise-induced hearing loss. J Neurosci. 2009 Nov 11;29(45):14077-85. (c) Lin HW, Furman AC, Kujawa SG and Liberman MC (2011) Primary neural degeneration in the guinea pig cochlea after reversible noise-induced threshold shift. JARO 12:605-616. (d) Furman AC, Kujawa SG, Liberman MC (2013) Noise-induced cochlear neuropathy is selective for fibers with low spontaneous rates. J. Neurophysiol.110, 577-586. 4. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. 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 or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs