Citation Nr: 1754038 Decision Date: 11/28/17 Archive Date: 12/07/17 DOCKET NO. 06-08 919 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Whether new and material evidence has been received in order to reopen claims of entitlement to service connection for major depression with psychotic features and a personality disorder, claimed as secondary to service-connected chronic bronchitis with bronchiectasis. 2. Entitlement to a rating in excess of 30 percent for chronic bronchitis with bronchiectasis (hereinafter, referred to as 'bronchitis'). 3. Entitlement to an initial compensable rating for bilateral hearing loss. 4. Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for a neck disorder. 5. Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for a right shoulder disorder. 6. Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for a bilateral hand disorder. 7. Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for a left eye disorder, to include glaucoma. 8. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran INTRODUCTION The Veteran had active duty service from January 1965 to January 1967 with additional Reserve service. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in October 2004 (bronchitis), July 2012 (hearing loss), and April 2013 (1151 claims and claim to reopen) by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2016, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A hearing transcript has been associated with the record on appeal. At such time, the Veteran declined to have a representative accompany him. At the hearing, the Veteran inquired as to the status of his claim regarding whether an October 2005 Board decision should be revised or reversed on the grounds of clear and unmistakable error. He is advised that such motion was dismissed by the Board in December 2010 based on his representative's withdrawal of the motion in light of the United States Court of Appeals for Veterans Claims (Court)'s May 2008 decision affirming the October 2005 Board decision. Additionally, in a January 2017 submission and elsewhere, the Veteran has repeatedly referenced issues that are not on appeal, including entitlement to compensation for a left shoulder injury he purports is the result of improper VA care. The Veteran is advised that, effective March 24, 2015, a claim for benefits must be submitted on an application form prescribed by the Secretary. See Standard Claims and Appeals Forms, 79 Fed. Reg. 57, 660 (Sept. 25, 2014). Consequently, if he wishes to pursue any additional claims, he should submit such application form to his RO. As the Veteran contends that he is unemployable due to his service-connected bronchitis, the Board has included the issue of entitlement to a TDIU on the title page of this decision. Rice v. Shinseki, 22 Vet. App. 447 (2009). The issues of entitlement to compensation under the provisions of 38 U.S.C. § 1151 for a left eye disorder and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In a final decision issued in April 1996, the RO denied service connection for major depression with psychotic features as secondary to service-connected bronchitis. 2. Evidence added to the record since the final April 1996 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for major depression with psychotic features as secondary to service-connected bronchitis. 3. In a final decision issued in August 2008, the RO denied service connection for a personality disorder (claimed as a mental disorder) as secondary to service-connected bronchitis. 4. Evidence added to the record since the final August 2008 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for a personality disorder (claimed as a mental disorder) as secondary to service-connected bronchitis. 5. For the entire the appeal period, the Veteran's bronchitis has not more nearly approximated FEV-1(Forced Expiratory Volume in One Second) of 40 to 55 percent predicted; or FEV-1/Forced Vital Capacity (FVC) of 40 to 55 percent; or Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) 40 to 55 percent predicted; and does not result in maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, or episode(s) of acute respiratory failure; requires outpatient oxygen therapy; further, his chronic bronchitis has not more nearly approximated incapacitating episodes of infection of four to six weeks or more total duration per year; nor near constant findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis and requiring antibiotic usage almost continuously. 6. For the entire appeal period, the Veteran had no worse than Level I hearing in the right ear and no worse than Level I hearing in the left ear. 7. An additional disability of the neck did not result from VA treatment. 8. An additional disability of the right shoulder did not result from VA treatment. 9. An additional disability of the hands did not result from VA treatment. CONCLUSIONS OF LAW 1. The April 1996 rating decision that denied service connection for major depression with psychotic features as secondary to service-connected bronchitis is final. 38 U.S.C. § 7105 (c) (West 1991) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (1995) [(2017)]. 2. New and material evidence to reopen the Veteran's claim of entitlement to service connection for a major depression with psychotic features as secondary to service-connected bronchitis has not been received. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The August 2008 rating decision that denied service connection for a personality disorder (claimed as a mental disorder) as secondary to service-connected bronchitis is final. 38 U.S.C. § 7105 (c) (West 2002) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2008) [(2017)]. 4. New and material evidence to reopen the Veteran's claim of entitlement to service connection for a personality disorder (claimed as a mental disorder) as secondary to service-connected bronchitis has not been received. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 5. The criteria for a rating in excess of 30 percent for bronchitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.27, 4.96, 4.97, Diagnostic Code (DC) 6600-6601 (2017). 6. The criteria for an initial compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.85, 4.86, DC 6100 (2017). 7. The criteria for compensation under the provisions of 38 U.S.C. § 1151 for a neck disorder are not met. 38 U.S.C. §§ 1151, 5107 (2012); 38 C.F.R. §§ 3.102, 3.361 (2017). 8. The criteria for compensation under the provisions of 38 U.S.C. § 1151 for a right shoulder disorder are not met. 38 U.S.C. §§ 1151, 5107 (2012); 38 C.F.R. §§ 3.102, 3.361 (2017). 9. The criteria for compensation under the provisions of 38 U.S.C. § 1151 for a bilateral hand disorder are not met. 38 U.S.C. §§ 1151, 5107 (2012); 38 C.F.R. §§ 3.102, 3.361 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000); Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). While the Veteran has made vague challenges as to the competence and impartiality of VA employees generally, which will be discussed in detail herein, neither he nor his representative has alleged any deficiency with respect to VA's duties to notify or assist. See Scott, supra (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 duty to assist argument). II. Application to Reopen Previously Denied Claim By way of background, in 1996, the Veteran filed his original claim for service connection for major depressive disorder. In a decision dated in March 1996 and issued in April 1996, the AOJ considered the Veteran's service treatment records (STRs), post-service medical records, and lay statements, and denied service connection as there was no evidence the Veteran's then-diagnosed psychiatric disorders were related to his bronchitis. However, no further communication regarding his claim of entitlement to service connection for a psychiatric disorder was received until December 2007, when VA received his application for service connection for a mental disorder. Further, no new and material evidence was received within one year of the notification of the decision, and no relevant service department records have been received since the issuance of such decision. Therefore, the April 1996 decision is final. See 38 U.S.C. § 7105(c) (West 1991) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (1995) [(2017)]; see also Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). Thereafter, the Veteran again filed a claim for service connection for a mental disorder in December 2007. In a July 2008 rating decision that was issued in August 2008, the AOJ denied service connection for a personality disorder (claimed as mental disorder) as secondary to service-connected bronchitis. In this regard, the AOJ noted that a personality disorder is considered a congenital or developmental defect that is unrelated to military service, and is not subject to service connection. The AOJ further found that the evidence did not show that the Veteran's claimed mental disorder is related to his service-connected bronchitis or his military service. The Veteran filed a notice of disagreement in October 2008 and a statement of the case (SOC) was issued in September 2009. In this regard, the SOC continued the denial of the Veteran's claim on the basis that his claimed psychiatric disorder was not shown to be caused or aggravated by his service-connected bronchitis, or directly related to his military service. Thereafter, no further communication regarding his claim of entitlement to service connection for a psychiatric disorder was received until May 2010, when the Veteran requested to reopen his claim for service connection for depression. Thus, he did not perfect his appeal within 60 days of the reissuance of the September 2009 SOC. Further, no new and material evidence was received within the remainder of the appeal period, and no relevant service department records have been received since the issuance of such decision. Therefore, the August 2008 decision is final. See 38 U.S.C. § 7105 (c) (West 2002) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2008) [(2017)]; see also Bond, supra. Generally, a claim which has been denied in an unappealed Board decision or an unappealed AOJ decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The United States Court of Appeals for Veterans Claims (Court) has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). As noted previously, service connection for major depression with psychotic features was denied in the April 1996 rating decision because, while there was evidence of current psychiatric diagnoses, such had not been shown to be related to the Veteran's service-connected bronchitis. Further, the Veteran's claim for service connection for a personality disorder (claimed as a mental condition) was denied in the August 2008 rating decision on the basis that a personality disorder is considered a congenital or developmental defect that is unrelated to military service, and is not subject to service connection. The AOJ further found that the evidence did not show that the Veteran's claimed mental disorder is related to his service-connected bronchitis or his military service. At the time both decisions were rendered, the AOJ considered the Veteran's statements, STRs, and post-service private and VA treatment records. Additionally, the Veteran's Social Security Administration (SSA) records were considered in association with the July 2008 decision. The evidence received since the April 1996 and August 2008 rating decisions includes lay statements from the Veteran (including his June 2016 hearing testimony), VA treatment records, private treatment records, and VA examination reports related to other disabilities. However, while new, such evidence is cumulative and redundant of evidence previously of record at the time of the prior rating decisions and does not relate to an unestablished fact or raise a reasonable possibility of substantiating the Veteran's claim for service connection for an acquired psychiatric disorder, to include major depression with psychotic features, or a personality disorder. In this regard, the lay statements and hearing testimony include duplicative information regarding the Veteran's theory of entitlement. Specifically, the Veteran continues to allege that the economic impairment he feels his service-connected bronchitis has caused has led to his psychiatric disabilities. In this regard, the Board notes that the Veteran has never alleged that his psychiatric disorder had its onset in, or is otherwise directly related to, his military service. Furthermore, much of the newly received medical evidence is irrelevant as it relates to the Veteran's other claims on appeal and does not include evidence relating his psychiatric disabilities to his service-connected bronchitis or military service. While the record now demonstrates various psychiatric diagnoses and the Board is aware of the Court's holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009), there is simply no competent evidence linking any currently diagnosed psychiatric disorder to the Veteran's military service or service-connected disabilities such that the claim could be reasonably substantiated in relation to any diagnosis. In addition to being cumulative and redundant, the Veteran's submissions and his testimony, while accepted as credible, are not competent to address the underlying issue of a nexus between his psychiatric disorders and his military service or service-connected bronchitis. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("[a]lthough the Veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with"); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In this regard, his statements do not provide a reasonable basis for establishing the claim. Therefore, the Board finds that the evidence received since the April 1996 and August 2008 final RO decisions is cumulative or redundant of the evidence of record at the time of the prior decisions and does not raise a reasonable possibility of substantiating the Veteran's claims for service connection for major depression with psychotic features and a personality disorder. Consequently, new and material evidence has not been received to reopen such claims and the Veteran's appeal must be denied. As new and material evidence to reopen the finally disallowed claims of entitlement to service connection has not been received, the benefit of the doubt doctrine is not applicable. Annoni v. Brown, 5 Vet. App. 463, 467 (1993). III. Increased Ratings Claims Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. Bronchitis The Veteran contends that a rating in excess of 30 percent for his bronchitis is warranted so as to more accurately reflect the severity of his symptomatology, which includes shortness of breath (especially when taking stairs or walking up hills), coughing that is occasionally productive, the use of medication, his perception of being more susceptible to germs, his subjective belief that he is incapacitated from his bronchitis for more than six weeks a year, and weakness. As an initial matter, the Board notes that, as the Veteran's chronic cough and bronchiectasis have been deemed to be symptoms of (chronic cough) or related to (bronchiectasis) his bronchitis, the symptoms of such bronchial disorders are contemplated by the Board herein. However, as an October 2014 VA examiner indicated the Veteran suffers from asthma that is not related to his bronchitis, such condition has not been considered in association with the instant decision. Nevertheless, the October 2014 examiner did not note any symptoms attributable to asthma and the record is otherwise void of any findings linking the Veteran's current respiratory symptoms specifically to asthma. Accordingly, the Veteran's disability picture with regard to all of his respiratory symptoms has been considered herein as attributable to his service-connected bronchitis. Mittleider v. West, 11 Vet. App. 181 (1998). The Veteran's bronchitis is rated as 30 percent disabling pursuant to 38 C.F.R. § 4.97, DC 6600-6601. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Under DC 6601, a 30 percent evaluation is assigned for bronchiectasis with incapacitating episodes (an incapacitating episode is one that requires bedrest and treatment by a physician) of infection of two to four weeks total duration per year or; daily productive cough with sputum that is at times purulent or blood-tinged and that requires prolonged (lasting four to six weeks) antibiotic usage more than twice a year. A 60 percent evaluation is assigned for bronchiectasis with incapacitating episodes of infection of four to six weeks total duration per year, or near constant findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis and requiring antibiotic usage almost continuously. A 100 percent evaluation is assigned for bronchiectasis with incapacitating infection episodes of at least six weeks total duration per year. Id. DC 6601 also permits rating under code 6600 for chronic bronchitis. Under DC 6600, a 30 percent rating is warranted where FEV-1 is 56 to 70 percent of predicted, or; the ratio of FEV-1/FVC is 56 to 70 percent, or; DLCO (SB) is 56 to 65 percent of predicted. 38 C.F.R. § 4.97, DC 6600. A 60 percent rating is warranted where FEV-1 is 40 to 55 percent of predicted value, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). Id. A 100 percent (total) rating is warranted if FEV-1 is less than 40 percent of predicted value, or; with FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40 percent predicted, or; with maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; with cor pulmonale (right heart failure), or; with right ventricular hypertrophy, or; with pulmonary hypertension (shown by Echo or cardiac catheterization), or; with episode(s) of acute respiratory failure, or if the veteran requires outpatient oxygen therapy. Id. Effective on October 6, 2006, after the receipt of the Veteran's claim for an increased rating, VA added provisions that clarify the use of pulmonary function test (PFT) results in evaluating respiratory conditions; however, such did not alter specific ratings under the affected DCs. See 71 Fed. Reg. 52459 (Sept. 6, 2006) (codified at 38 C.F.R. § 4.96(d)). This regulation entitled "Special provisions for the application of evaluation criteria for diagnostic codes 6600, 6603, 6604, 6825-6833, and 6840-6845" has seven subsections. 38 C.F.R. § 4.96(d)(1)-(7). PFTs are required except: (i) when the results of a maximum exercise capacity test are of record and are 20 ml/kg/min or less; if a maximum exercise capacity test is not of record, evaluation is based on alternative criteria; (ii) when pulmonary hypertension (documented by an echocardiogram or cardiac catheterization), cor pulmonale, or right ventricular hypertrophy has been diagnosed; (iii) when there have been one or more episodes of acute respiratory failure; or (iv) when outpatient therapy oxygen is required. 38 C.F.R. § 4.96(d)(1). If the DLCO(SB) test is not of record, evaluation is based on alternative criteria as long as the examiner states why the test would not be useful or valid in a particular case. 38 C.F.R. § 4.96(d)(2). When the PFTs are not consistent with clinical findings, evaluation is based on the PFTs unless the examiner states why they are not a valid indication of respiratory functional impairment in a given case. 38 C.F.R. § 4.96(d)(3). Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when the results of pre-bronchodilator PFTs are normal or when the examiner determines that post-bronchodilator tests should not be done and states why. 38 C.F.R. § 4.96(d)(4). When evaluating based on PFTs, post-bronchodilator results are used in applying evaluation criteria in the rating schedule unless the post-bronchodilator results were poorer than the pre-bronchodilator results, in which case the pre-bronchodilator values are used for rating purposes. 38 C.F.R. § 4.96(d)(5). When there is a disparity between the results of different PFTs (FEV-1, FVC, etc.), so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96(d)(6). Finally, if the FEV-1 and the FVC are both greater than 100 percent, a compensable evaluation based on a decreased FEV-1/FVC ratio should not be assigned. 38 C.F.R. § 4.96(d)(7). The appeal period before the Board begins on December 18, 2003, the date VA received the Veteran's claim for an increased rating for his chronic bronchitis, plus the one-year look-back period. Gatson v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The Board finds that the Veteran is not entitled to a rating in excess of 30 percent for his bronchitis at any point during the appeal period under DC 6601. In this regard, a 60 percent rating is warranted for bronchiectasis with incapacitating episodes of infection of four to six weeks total duration per year, or near constant findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis and requiring antibiotic usage almost continuously. In this case, the evidence demonstrates that a VA clinician only recommended bedrest once in January 2015 and a period of time was not specified. See May 2016 addendum opinion. Further, while an October 2014 VA examiner opined the Veteran's chronic bronchitis caused incapacitating episodes of six weeks or more in the previous year, this position was based entirely on the Veteran's lay reports, which are unsubstantiated and uncorroborated by the contemporaneous records, and thus not credible. Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005); Coburn v. Nicholson, 19 Vet. App. 427, 432 (2006) (reliance on a veteran's statement renders a medical report incredible only if the Board rejects the statement of the veteran). Therefore, such opinion is accorded no probative weight. In this regard, January 2008 and May 2010 VA examiners who reviewed the Veteran's medical records and claims file noted the Veteran had no history of bronchitis related bedrest or hospitalization. More recently, in May 2016, a VA examiner reviewed the available treatment records and specifically found there was no evidence of prolonged bedrest, hospitalizations, or prolonged antibiotic courses or incapacitating episodes by VA's criteria. Thus, the medical evidence does not support a finding of incapacitating episodes related to bronchitis. Moreover, even if the Veteran self-confined himself to bed for extended periods during the appeal period, there is no evidence that such was accompanied by treatment from a physician, which is required for the episode to be deemed incapacitating for VA purposes. Further, while there is evidence suggesting the Veteran has frequent coughing with occasional purulent discharge, and he reported to a January 2008 examiner that he has experienced weight loss related to such, there is no evidence to support a finding of anorexia, frank hemoptysis, and nearly continuous use of antibiotics. Indeed, a June 2004 VA examiner noted the Veteran had only been prescribed three courses of antibiotics in the last year and a half, a January 2008 examiner verified the Veteran had been prescribed only 20 days' worth of antibiotics in 2006, and a May 2010 examiner noted the Veteran had only been prescribed 60 days' worth of antibiotics from March 2006 to May 2010. Then, in October 2014, the examiner only noted twice yearly prescriptions for antibiotics, and a May 2016 examiner noted the Veteran had only been prescribed 15 days' worth of antibiotics in 2015. Further, the 2010 examiner only noted one prescription for antibiotics in 2007 and stated that, by 2008, the Veteran demonstrated "excellent control" of his pulmonary symptoms. In 2009, following a bought of right lower lobe early pneumonia, he was provided with two courses of antibiotics, one of which was to be taken on an as needed basis for increased sputum production, which the Veteran denied using at the time of a May 2010 VA examination. Thus, there is no evidence of near continuous use of antibiotics. Instead, there is evidence the Veteran was treated with antibiotics on an as-needed basis in relation to respiratory infections. Further, the Veteran denied experiencing hemoptysis during the January 2008 examination and, in May 2010, he only endorsed occasional flecks of blood with violent coughing during a 2009 bought of pneumonia. In fact, the May 2010 examiner specifically stated the Veteran did not have a history of near constant findings of cough with purulent sputum associated with anorexia, weight loss and frank hemoptysis requiring antibiotic usage almost continuously. Ultimately, as there is no evidence of incapacitating episodes requiring bedrest and treatment by a physician for four to six weeks or more or near continuous use of antibiotics with constant cough, weight loss or anorexia or frank hemoptysis, a rating in excess of 30 percent is not warranted under DC 6601. Additionally, a rating in excess of 30 percent is similarly not warranted under DC 6600. In this regard, a 60 percent rating is warranted when FEV-1 is 40 to 55 percent of predicted value, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). As an initial matter, the Board has accepted all of the PFT evidence of record regardless of compliance with 38 C.F.R. § 4.96(d) in light of the fact that, as noted above, such regulation was not effective until after the Veteran filed his claim for an increased rating. Nevertheless, the evidence indicates the Veteran's FEV-1 was, at worst, 107 percent predicted (see October 2014 VA examination report), his FEV-1/FVC was, at worst, 103 percent predicted (see June 2004 VA examination report), and his DLCO was, at worst, 74 percent predicted (see May 2005 VA treatment record). Such results do not support a 60 percent rating under DC 6600. In sum, the Board finds the most probative evidence of record does not reflect that the Veteran has manifested symptoms that more nearly approximate the level of disability to warrant a rating in excess of 30 percent at any time during the appeal period, including based on PFT findings or lay or medical evidence of other associated symptomatology, such as cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, episodes of acute respiratory failure, or requiring oxygen therapy. Further, the evidence does not reflect the Veteran's service-connected bronchitis is manifested by interstitial or restrictive lung disease; nor does the evidence reflect that there are any other associated or resultant conditions or disabilities, such as scars, for which a separate or increased rating should be assigned. In this regard, the Board has considered the Veteran's service-connected chronic bronchitis under all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, as discussed above, the evidence of record does not establish entitlement to a rating higher than 30 percent for the Veteran's service-connected disability based upon the criteria used to evaluate bronchitis or bronchiectasis, which are the primary residual conditions of his bronchial disability, and there are no other DCs that provide a basis to assign a separate or higher rating than the 30 percent rating currently assigned. Hearing Loss The Veteran's service-connected bilateral hearing loss has been assigned a noncompensable rating under 38 C.F.R. § 4.85, DC 6100, as of August 11, 2008. Ratings of hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second. To rate the degree of disability for service-connected hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85(h), Table VI. In order to establish entitlement to a compensable rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average pure tone decibel loss are met. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. These results are then charted on Table VI, or Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII, as set out in the Rating Schedule. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. The Veteran was afforded a VA audiological examination in June 2012 in connection with his claim for service connection. At that time, he reported difficulty understanding conversations in background noise. Audiological testing revealed the following pure tone thresholds in decibels: 2012 HERTZ 1000 2000 3000 4000 AVG. RIGHT 25 35 45 50 39 LEFT 30 40 55 60 46 Word recognition testing revealed speech recognition ability of 100 percent in the right ear and 98 percent in the left ear. No exceptional pattern of hearing loss was demonstrated. These audiometry test results equate to Level I hearing in the right and left ears. 38 C.F.R. § 4.85. Applying the percentage ratings for hearing impairment found in Table VII, Level I hearing in one ear and Level I hearing in the other ear results in a noncompensable rating. Id. The Veteran was afforded a second VA audiological examination in October 2014, at which time he continued to report difficulty hearing with background noise present. Audiological testing revealed the following pure tone thresholds in decibels: 2014 HERTZ 1000 2000 3000 4000 AVG. RIGHT 30 40 55 55 45 LEFT 30 40 55 55 45 Word recognition testing revealed speech recognition ability of 100 percent in the right ear and 96 percent in the left ear. No exceptional pattern of hearing loss was demonstrated. These audiometry test results equate to Level I hearing in the right and left ears. 38 C.F.R. § 4.85. Applying the percentage ratings for hearing impairment found in Table VII, Level I hearing in one ear and Level I hearing in the other ear results in a noncompensable rating. Id. During a third VA audiological examination conducted in February 2016, the Veteran reported discontinuing his attendance of local meetings due to his inability to hear or participate related to his hearing loss. Audiological testing revealed the following pure tone thresholds in decibels: 2016 HERTZ 1000 2000 3000 4000 AVG. RIGHT 30 40 50 55 44 LEFT 30 45 55 55 46 Word recognition testing revealed speech recognition ability of 100 percent in both ears. No exceptional pattern of hearing loss was demonstrated. These audiometry test results equate to Level I hearing in the right and left ears. Id. As noted above, Level I hearing in both ears results in a noncompensable rating. Id. During the June 2016, Board hearing, the Veteran reported he was unable to hear during city council meetings, missed words when others spoke, asked others to repeat themselves, and experiencing pronounced difficulty in understanding speakers with accents. To the extent that the Veteran contends that his hearing loss is more severe than currently evaluated, the Board observes that the Veteran, while competent to report symptoms, is not competent to report that his hearing acuity is of sufficient severity to warrant a higher evaluation under VA's tables for rating hearing loss disabilities because such an opinion requires medical expertise (training in evaluating hearing impairment), which he has not been shown to possess. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, supra; Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Despite the foregoing, the Board acknowledges the Veteran's belief that his bilateral hearing loss is severe enough to justify a compensable rating and observes that the VA examiners inquired as to the functional impact of such pursuant to Martinak v. Nicholson, 21 Vet. App. 447 (2007). However, even after considering such contentions, the Board finds that the criteria for a compensable rating are not met. See Lendenmann, supra (assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered). Other Considerations The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his bronchitis and hearing loss. The Board also acknowledges that the Veteran, in advancing this appeal, believes that the disabilities on appeal have been more severe than the assigned disability ratings reflect. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. In this regard, at the June 2016 Board hearing, the Veteran reported reading and owning numerous medical treatises in support of his contention that he possesses some medical expertise. Nevertheless, the record does not demonstrate that he possesses clinical or diagnostic medical knowledge or skills in excess of the numerous VA examiners who evaluated his bronchitis and hearing loss during the appeal period. In this regard, the VA examiners included three audiologists (2012, 2014, and 2016 hearing examiners), an attending pulmonary physician (2004 bronchial examiner), three physicians (2008, 2014, and 2016 bronchial examiners), and a nurse practitioner (2010 bronchial examiner), who have greater training and skill in evaluating the specific medical conditions at issue than the Veteran. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). Therefore, his own assessments as to the severity of the symptoms and their relationship to the rating criteria are deemed less probative than the opinions of medical practitioners who have specialized knowledge and skill in excess of the Veteran. The Veteran has been an active participant in his appeal and has submitted vague statements that could be construed as challenging the validity of his examinations or any work performed by government employees in general. However, a VA examiner is presumed to have properly discharged her duties as a health professional (presumption of regularity) in a review of the record, in interviewing the Veteran, and supporting her opinion with medical analysis applied to the significant facts of the case. See Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed Cir. 2009) (applying the presumption of regularity to VA medical examiners in the discharge of their regular duties). The presumption of regularity is only rebuttable by clear evidence to the contrary. Miley v. Principi, 366 F.3d 1343, 1347 (Fed. Cir. 2004). Here, the Veteran has not provided clear evidence to rebut the presumption of regularity. Instead, he has voiced his general dissatisfaction with the appeals process, with VA, and with other government entities and persons generally. As he has not demonstrated that the VA examiners were unaware of any significant fact in his case or introduced any evidence that shows a lack of impartiality or incompetence, the Veteran has not met his burden to show that the VA examinations are inadequate and the Board finds his arguments in this regard to be unpersuasive. Hilkert v. West, 12 Vet. App. 145, 151 (1999) (an appellant bears the burden of persuasion to show that the Board's reliance on an examiner's opinion was in error). The Board has considered whether staged ratings under Hart, supra, and Fenderson, supra, are appropriate for the Veteran's service-connected chronic bronchitis or hearing loss; however, the Board finds that his symptomatology has been stable throughout the appeal periods. Therefore, assigning staged ratings for such disabilities is not warranted. In Doucette v. Shulkin, 28 Vet. App. 366 (2017), the Court held that the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment as these are the effects that VA's audiometric tests are designed to measure. The Veteran has not otherwise described functional effects that are considered exceptional or, that are not otherwise contemplated by the assigned evaluation. Id. Further, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. Id. (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). IV. 38 U.S.C. § 1151 Claims The Veteran contends that he is entitled to compensation under the provisions of 38 U.S.C. § 1151 for a neck disorder, right shoulder disorder, and bilateral hand disorder. In this regard, he alleges that VA mistreated his neck and shoulder in October 2007 by not performing immediate imaging studies and that said mistreatment lead to the development of an additional bilateral hand disorder. See June 2016 hearing transcript. Compensation under 38 U.S.C. § 1151 is awarded for a qualifying additional disability caused by improper VA treatment. A disability is a qualifying additional disability if the disability was not the result of the Veteran's willful misconduct and the disability was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by the Secretary of the VA, either by a Department employee or in a Department facility and the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or an event not reasonably foreseeable. 38 U.S.C. § 1151; 38 C.F.R. § 3.361. In Viegas v. Shinseki, the Federal Circuit noted that section 1151 delineates three prerequisites for obtaining disability compensation. First, a putative claimant must incur a "qualifying additional disability" that was not the result of his own "willful misconduct." 38 U.S.C. § 1151(a). Second, that disability must have been "caused by hospital care, medical or surgical treatment, or examination furnished the Veteran" by VA or in a VA facility. Finally, the "proximate cause" of the Veteran's disability must be "carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part" of VA, or "an event not reasonably foreseeable." See Viegas v. Shinseki, 705 F.3d 1374 (Fed. Cir. 2013); § 1151(a)(1)(A), (a)(1)(B). Thus, section 1151 contains two causation elements-a Veteran's disability must not only be caused by the hospital care or medical treatment he received from VA, but also must be proximately caused by the VA's fault or an unforeseen event. In determining whether a Veteran has an additional disability, VA compares the Veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the Veteran's condition after care or treatment is rendered. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the Veteran's additional disability. Merely showing that a Veteran received care or treatment and that the Veteran has an additional disability does not establish causation. 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease of injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a Veteran's additional disability, it must be shown that the hospital care or medical or surgical treatment caused the Veteran's additional disability; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (ii) VA furnished the hospital care or medical or surgical treatment without the Veteran's informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a Veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). VA treatment records show that, in October 2007, the Veteran sought emergency treatment after being assaulted on public transit. He reported there was relatively little force during the attack, but he experienced worsening neck, right shoulder, and bilateral hand pain thereafter. The Veteran reports having asked for imaging studies to be performed in October 2007, but the treating clinician declined to do so. Instead, based on his physical presentation on examination, the Veteran was advised to work with his physical therapist to develop an exercise program related to healing his injuries. X-rays were performed in March 2008 and, in December 2008, he had an MRI of the cervical spine. Surgical repair of the spine occurred in April 2009 and arthroscopic right shoulder surgery was performed in October 2008. See March 2013 VA examination report. In March 2013, a VA physician noted a comprehensive review of the Veteran's medical records with special attention to the events surrounding his October 2007 emergency room treatment. The examiner indicated there was no significant abnormal pathology with regard to the Veteran's hands and previous imaging studies had been normal. He further observed that, based on the Veteran's presentation the day of his assault, his injuries appeared to be soft tissue in nature and over the counter medication was an appropriate treatment for such. Thereafter, the Veteran did not report neck or shoulder pain until over a month after the assault, despite having sought treatment in the interim where he did not mention shoulder or neck pain. The examiner noted that, even a month later, evaluation of the Veteran revealed a mild soft tissue cervical injury. It was further noted that March 2008 x-rays were unremarkable for the Veteran's age. Based on the foregoing, the examiner found the Veteran's course of treatment had been very reasonable and appropriate based on the symptoms the Veteran conveyed to treating clinicians. Indeed, the examiner observed the Veteran was immediately referred for imaging studies when conservative treatment proved ineffective. Ultimately, the examiner indicated that, even if the Veteran had been referred for x-rays immediately, it would not have changed his eventual need for surgery and the delay did not worsen his neck, right shoulder, or bilateral hand symptoms. Thereafter, in November 2014, the Veteran was afforded VA orthopedic examinations of his neck, right shoulder, and hands and an addendum opinion was obtained in May 2016 in light of the potentially relevant information contained in the 2014 examination reports. The May 2016 examiner noted a review of the record, which includes the VA treatment records, numerous submissions from the Veteran, and the Veteran's lay statements. The examiner was asked whether the Veteran incurred any additional disability to the neck, right shoulder, or bilateral hands as a result of his VA treatment, to include as due to the lack of proper treatment, specifically, the postponement of imaging studies in October 2007. Ultimately, the examiner found that it was less likely than not that the Veteran's neck, right shoulder, or hands sustained an additional disability or increase in severity as a result of VA care that was adequate and appropriate. With regards to the Veteran's neck, the examiner acknowledged the Veteran's October 2007 report of pain, but noted standard protocol did not require imaging studies because there was no evidence of a bony injury or neurologic complaints. Further, the examiner noted the mechanism of the Veteran's injury could not have caused a spinal injury as the Veteran's imaging studies revealed degenerative changes and not acute trauma, single level disc disease, or a healing fracture, which would be expected if the 2007 injury caused his neck disorder. Further, the examiner observed that medical knowledge shows that it is natural for the degenerative process to change over time and eventually lead to surgical intervention. Indeed, it was noted that, even if imaging studies had been performed in October 2007, the treatment the Veteran received (conservative) would not have changed. Turning to the Veteran's right shoulder, the examiner observed that the treatment rendered to the shoulder was entirely appropriate given the mechanism of injury and findings on examination. In this regard, there were no "red flag physical findings" at the time of the October 2007 treatment and, as such, medical literature supports conservative treatment especially for "older patients with multiple comorbidities, [like the] Veteran who also suffers from pulmonary disease." Like the Veteran's neck, even if imaging studies had been performed in October 2007, medical professionals would have rendered the same care given the variable progression of shoulder tears that can only be assessed over time. Finally, with regards to the Veteran's hands, the examiner initially noted the Veteran did not report experiencing any hand symptoms immediately following the 2007 assault and had, in fact, been reporting hand symptoms for some time prior to the 2007 event. Moreover, while the Veteran did seek treatment for hand pain following the attack, he self-associated such pain with increased typing. Furthermore, the examiner noted there was no significant change in the Veteran's hand x-rays from 1991 to 2014, indicating there was no worsening of his degenerative disease by VA treatment (or lack thereof). Thus, the examiner concluded the Veteran's current hand disorder is related to overuse and not treatment rendered (or withheld) following the 2007 incident in relation to the Veteran's neck, shoulder, or hands. Further, the treatment the Veteran was offered in relation to his overuse was consistent with current medical literature. The Board finds that compensation under 38 U.S.C. § 1151 for a neck, right shoulder, or hand disorder is not warranted because the VA care provided to the Veteran did not result in an additional disability or an increase in severity of existing disorders. Initially, the Board accords great probative weight to the May 2016 opinion, which is supported by the only other competent etiology opinion of record, the March 2013 opinion, and it is predicated on a thorough review of the record, which includes medical records concerning the treatment in question and the Veteran's statements, in which his contentions are fully articulated. Additionally, such opinion considered all of the pertinent evidence of record and provided a complete rationale, relying on and citing to the records received. Moreover, the clinician offered a clear conclusion with supporting data. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). The Board acknowledges the Veteran's sincerely held belief that, had imaging studies been performed in October 2007, he would not have subsequently had neck and shoulder surgery and would not have developed a hand disorder. While the Veteran purports to have medical knowledge based on his reading of medical treatises, the record does not demonstrate that he possesses clinical or diagnostic medical knowledge or skills in excess of the May 2016 or March 2013 VA examiners. In this regard, the VA examiners were physicians, who, as noted above, have greater training and skill in evaluating medical conditions and practices than the Veteran. See Black, supra. Additionally, while the Veteran, as a lay person, may report on his observable symptoms and discomfort and the nature of the treatment he received, an assessment of the severity and proper treatment for his symptoms is a complex, medical matter requiring training and clinical experience that the Veteran does not possess. Therefore, his own assessment of the severity of the symptoms, the need for alternative treatment, and the required course of treatment are not competent as such are complex medical questions and his statements in this regard are non-probative. See Jandreau, supra. Additionally, for the reasons discussed above, the Board finds the Veteran's vague challenges to the VA evidence of record to be unpersuasive in light of their failure to identify any specific defects in same. Therefore, the Board places the greatest probative weight on the thorough analysis by the 2016 VA examiner. The examiner considered the Veteran's contentions and accurately summarized the medical history. The assessment of the symptoms and their severity is consistent with the available medical records. The examiner explained that the standard of care was appropriate and the record does not contain any opinion from a medical professional indicating that VA care caused the Veteran to incur an additional disability or increased an existing disability as a result of improper care. As the most probative evidence of record shows that the Veteran did not incur additional disabilities or an increase in the severity of existing disabilities as a result of proper and appropriate VA treatment, the "benefit of the doubt" rule is not for application, and the Board must deny the claims. See 38 U.S.C. § 5107(b); Gilbert, supra. ORDER New and material evidence not having been received, the application to reopen claims of entitlement to service connection for major depression with psychotic features and a personality disorder as secondary to service-connected bronchitis is denied. A rating in excess of 30 percent for bronchitis is denied. An initial compensable rating for bilateral hearing loss is denied. Compensation under 38 U.S.C. § 1151 for a neck disorder is denied. Compensation under 38 U.S.C. § 1151 for a right shoulder disorder is denied. Compensation under 38 U.S.C. § 1151 for a bilateral hand disorder is denied. REMAND Entitlement to Compensation Under the Provisions of 38 U.S.C. § 1151 The Veteran was afforded a VA examination in October 2012 and an addendum opinion was obtained in February 2013. Unfortunately, the opinions did not address the Veteran's theory of entitlement for his left eye glaucoma. Specifically, he reported at the June 2016 Board hearing that his left eye glaucoma was the result of VA's failure to properly diagnose and treat his interocular pressure, not the 2007 attack. Accordingly, the Board finds that an addendum opinion is necessary for appellate review. Id. TDIU Throughout the appeal, the Veteran has claimed that he is unable to work due to his service-connected bronchitis, hearing loss, and tinnitus. The record does not contain an opinion as to the combined impact of the Veteran's service-connected disabilities on his ability to work. As such, the Board finds that remand is required for procurement of an opinion that addresses the impact of all of the Veteran's service-connected conditions on his ability to work. Accordingly, the case is REMANDED for the following action: 1. Return the record to the VA examiner who provided the February 2013 opinion regarding the Veteran's left eye disorder. The record and a copy of this Remand must be made available to the examiner. The examiner shall note in the examination report that the record and the Remand have been reviewed. If the February 2013 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Upon a review of the record, the examiner should opine as to whether it at least as likely as not (a 50 percent or higher degree of probability) that the Veteran's left eye glaucoma or other disorder of the left eye was caused by or aggravated by VA medical care? In other words, please determine whether the Veteran has any additional disability or disabilities, to include glaucoma, as a result of the treatment administered by VA, and if so, please detail the nature of such disability or disabilities. In this regard, the Veteran has contended that he developed glaucoma as a result of the improper identification of and treatment of interocular pressure. If and only if you find that the Veteran has such additional disability, please proceed to the following questions. i) Is it at least as likely as not (a 50 percent or higher degree of probability) that any such additional disability or disabilities in the left eye is due to carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA in furnishing hospital care, medical or surgical treatment? ii) Is it at least as likely as not (a 50 percent or higher degree of probability) that any such additional disability or disabilities in the left eye is due to an event not reasonably foreseeable? A "not reasonably foreseeable" event is one that would not be reasonably anticipated or expected by a health care provider who utilized the degree of care a prudent or competent person so engaged would exercise. A complete rationale should be given for each opinion expressed. 2. Forward the record to an appropriate VA examiner so as to determine the functional impact of the Veteran's service-connected disabilities in combination on his ordinary activities, to include his employability. The record contents must be made available for review. The examiner is requested to describe the Veteran's employment history. The examiner should assess the functional impairment caused by the Veteran's service-connected disabilities of chronic bronchitis, tinnitus, and hearing loss, in the aggregate (i.e., jointly), on his ordinary activities, to include his employability, taking into consideration his level of education, special training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities, to include his apparent psychiatric disability. All opinions offered should be accompanied by a rationale. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs