Citation Nr: 1803315 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 14-14 240 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for bilateral hearing loss disability. 2. Entitlement to service connection for gastrointestinal reflux disease (GERD), to include as secondary to service-connected sinusitis. 3. Entitlement to service connection for sleep apnea, to include as secondary to service-connected sinusitis. 4. Entitlement to an increased disability rating in excess of 10 percent for left knee chondromalacia with patellofemoral pain syndrome. 5. Entitlement to an initial disability rating in excess of 10 percent for right knee patellofemoral pain syndrome. 6. Entitlement to an initial disability rating in excess of 10 percent for tinea versicolor. 7. Entitlement to an increased disability rating in excess of 20 percent for left palm neuritis. 8. Entitlement to an increased disability rating in excess of 10 percent for left palm scars. 9. Entitlement to an increased disability rating in excess of 30 percent for sinusitis. REPRESENTATION Appellant represented by: Robert Brown, Jr., Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. Chad Johnson, Counsel INTRODUCTION The Veteran had active service from February 2002 to September 2006. These matters come to the Board of Veterans' Appeals (Board) from May 2013, July 2013, and February 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. Jurisdiction over the Veteran's claims file was subsequently transferred to the RO in Winston-Salem, North Carolina. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a September 2017 videoconference hearing, and a transcript of the hearing has been associated with the claims file. To the extent that additional relevant evidence has been added to the claims file following the September Board hearing, the Board notes that the Veteran's attorney explicitly waived review of such evidence by the agency of original jurisdiction (AOJ) at the September 2017 Board hearing. 38 U.S.C. § 7105(e) (2012); 38 C.F.R. § 20.1304 (2017). The issues of entitlement to service connection for sleep apnea, to include as secondary to service-connected sinusitis, and bilateral hearing loss disability, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The preponderance of the evidence of record is against a finding that the Veteran has been diagnosed with gastrointestinal reflux disease (GERD) following diagnostic testing at any time during the pendency of the appeal; moreover, his claimed GERD condition did not have onset during active service and is not otherwise due to active service, to include as secondary to service-connected sinusitis. 2. For the entire period on appeal, the Veteran's left knee chondromalacia with patellofemoral pain syndrome has been manifested by no worse than limitation of extension to 10 degrees with pain and noncompensable limitation of flexion. 3. For the entire period on appeal, the Veteran's right knee patellofemoral pain syndrome has been manifested by no worse than noncompensable limitation of motion with pain. 4. For the entire period on appeal, the Veteran's tinea versicolor has been manifested by no worse than at least 5 percent, but less than 20 percent, of the entire body affected, with treatment including topical therapy, but without any related systemic therapy. 5. Prior to April 7, 2014, the Veteran's left palm neuritis was manifested by no worse than moderate incomplete paralysis of the median nerve. 6. From April 7, 2014, the Veteran's left palm neuritis was manifested by severe incomplete paralysis of the median nerve. 7. For the entire period on appeal, the Veteran's left palm scars were manifested by no worse than two painful linear scars on the left palm, which are not unstable. 8. For the entire period on appeal, the Veteran's service-connected sinusitis was manifested by no worse than chronic sinusitis resulting in 7 or more non-incapacitating episodes of sinusitis in a 12 month period which required constant medication and resulted in sinus congestion, sore throat, itchy and watery eyes, and headaches. CONCLUSIONS OF LAW 1. The criteria for service connection for gastrointestinal reflux disease (GERD), to include as secondary to service-connected sinusitis, have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 2. The criteria for an increased disability rating in excess of 10 percent for left knee chondromalacia with patellofemoral pain syndrome have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260 (2017). 3. The criteria for an initial disability rating in excess of 10 percent for right knee patellofemoral pain syndrome have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5261 (2017). 4. The criteria for an initial disability rating in excess of 10 percent for tinea versicolor have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.118, DC 7806 (2017). 5. The criteria for an increased 40 percent disability rating for left palm neuritis have been met from April 7, 2014, but no earlier. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.124a, DC 8615 (2017). 6. The criteria for an increased disability rating in excess of 10 percent for left palm scars have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.118, DC 7804 (2017). 7. The criteria for an increased disability rating in excess of 30 percent for sinusitis have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.97, DC 6513 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Neither the Veteran nor his attorney has raised any issues with the duty to notify. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the Veteran fails to raise them before the Board."). To the extent that the Veteran and his attorney have asserted generally that the April 2014 VA examiner was biased and therefore, the clinical findings cannot be trusted, the Board finds such arguments are not supported by the record. In this regard, a VA examiner is presumed to have properly discharged his or her duties as a health professional in a review of the record, in interviewing the Veteran, and supporting his or her opinion with medical analysis applied to the significant facts of the case. See Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009) (applying the presumption of regularity to VA medical examiners in the discharge of their regular duties). While the presumption of regularity is rebuttable by clear evidence to the contrary, the Board finds no indication that the April 2014 VA examiner failed to properly discharge his duties in rendering the various April 2014 VA examinations. See Miley v. Principi, 366 F.3d 1343, 1347 (Fed. Cir. 2004). Consequently, the Board finds that the various examination reports completed by the April 2014 VA examiner are adequate and highly probative evidence, as they reflect consideration of the Veteran's claims file, the Veteran's medical history, and all relevant facts; moreover, the examiner provided adequate detail to apply the relevant rating criteria. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Additionally, while the Board has herein acknowledged the Veteran's September 2017 Board testimony concerning a worsening in his claimed bilateral hearing loss, as discussed in the remand section below, the Board notes that the Veteran has not explicitly claimed that his other service-connected disabilities on appeal have worsened since the last examinations, and the probative evidence of record does not otherwise indicate that there has been a material worsening in the severity of the Veteran's service-connected disabilities since the last VA examinations of record. As such, remand of the Veteran's initial and increased rating claims for current VA examinations is not warranted. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (VA's duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted); see also 38 C.F.R. § 3.327(a) (2017); VAOPGCPREC 11-95. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the 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 and on what this evidence shows, or fails to show, regarding the Veteran's claim on appeal. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). II. Service Connection - GERD Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303(a) (2017). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017). Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability, but only that degree, over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310(b) (2017). The U.S. Court of Appeals for Veterans Claims (Court) has held that Congress 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, 225 (1992). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran claims entitlement to service connection for gastrointestinal reflux disease (GERD), to include as secondary to service-connected sinusitis. Notably, service treatment records do not document any complaints, treatment, or diagnosis of GERD. The Veteran denied indigestion or heartburn upon enlistment examination in December 2001 and upon separation examination in July 2006; he also denied related complaints upon repeated physical examinations throughout active service. VA treatment records from January 2013 document the Veteran's complaints of occasional heartburn symptoms with certain foods; he also reported that he had been told in the past that he likely had GERD, and the examining VA physician assessed "likely" GERD. The Veteran testified at his September 2017 Board hearing that a previous VA physician had diagnosed him with GERD and told him that it was related to his service-connected sinusitis. However, as noted above, the VA treatment records referred to by the Veteran from January 2013 simply document the Veteran's report of occasional heartburn and an assessment of "likely" GERD. The Board finds that this is no more than speculative evidence regarding the Veteran's claim, and of limited probative value regarding his claim. See Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Significantly, there is no probative evidence of record that the Veteran has been diagnosed with GERD as confirmed by diagnostic testing. As such, service connection for GERD is not warranted. See Brammer, 3 Vet. App. at 225. Moreover, there is no probative evidence that the Veteran's claimed GERD is related to his service-connected sinusitis. 38 C.F.R. § 3.310. Although the lay evidence of record, including the Veteran's September 2017 Board hearing testimony, is competent insofar as it relates observable symptoms, see Layno v. Brown, 6 Vet. App. 465, 469 (1994); to the extent that the Veteran asserts that he has GERD which is related to active service or his service-connected sinusitis, such statements are less probative, as the Veteran lacks the medical training in order to render a diagnosis or related nexus opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Given the above, the Board finds that the preponderance of the evidence weighs against the Veteran's claim of entitlement to service connection for GERD, to include as secondary to service-connected sinusitis. As such, there is no reasonable doubt to be resolved, and the claim must be denied. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Initial/Increased Ratings - Generally Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2017). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. § 4.1, 4.2 (2017); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2017). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2017). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. 38 C.F.R. § 4.14 (2017). Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. Id. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2017). Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding, see 38 C.F.R. § 4.14, do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. However, those provisions should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45 (2017). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2017). However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable diagnostic code. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Separate ratings may be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. See VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). Moreover, limitation of motion and instability of a knee may also be rated separately; in other words, evaluation of knee dysfunction based on both limitation of motion and instability does not amount to pyramiding under 38 C.F.R. § 4.14. See VAOPGCPREC 23-97 (July 1, 1997) and VAOPGCPREC 09-98 (August 14, 1998). Therefore, limitation of motion and instability of the knee may be rated separately, provided that any separate rating must be based upon additional disability. Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). With respect to the Veteran's initial rating claims on appeal, the Board has considered such claims from the assigned effective dates, which the Veteran has not appealed. With respect to the Veteran's increased rating claims on appeal, the Board has considered the relevant temporal period including one year prior to the Veteran's June 2012 increased rating claim, as well as whether any additional staged rating periods are warranted. III.A. Increased Ratings - Bilateral Knees The Veteran seeks entitlement to an increased disability rating in excess of 10 percent for left knee chondromalacia with patellofemoral pain syndrome and an initial disability rating in excess of 10 percent for right knee patellofemoral pain syndrome. The Veteran's left knee disability is currently rated as 10 percent disabling under DC 5261, regarding limitation of extension of the leg, while his right knee disability is rated as 10 percent disabling under DC 5260, regarding limitation of flexion of the leg. See 38 C.F.R. § 4.71a, DCs 5260-61 (2017). Under DC 5260, a 10 percent disability rating is warranted for limitation of flexion to 45 degrees; a 20 percent disability rating is warranted for limitation of flexion to 30 degrees, and a maximum schedular 30 percent disability rating is warranted for limitation of flexion to 15 degrees. Id., DC 5260. Under DC 5261, a 10 percent disability rating is warranted for limitation of extension to 10 degrees; a 20 percent disability rating is warranted for limitation of extension to 15 degrees; a 30 percent disability rating is warranted for limitation of extension to 20 degrees; a 40 percent disability rating is warranted for limitation of extension to 30 degrees; and a maximum schedular 50 percent disability rating is warranted for limitation of extension to 45 degrees. Id., DC 5261. As regards range of motion, for rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. Id, Plate II. DC 5257, which addresses lateral instability and subluxation, provides for a 10 percent rating when there is slight recurrent subluxation or lateral instability. When there is moderate recurrent subluxation or lateral instability, a 20 percent rating is warranted. When there is severe recurrent subluxation or lateral instability, a 30 percent rating is warranted. Under DC 5258, a 20 percent evaluation is assigned for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Turning to the evidence of record, upon VA examination in November 2012, the Veteran reported symptoms of locking and hyperextension, including flare ups of pain with increased physical activity and weight bearing. Upon physical examination, initial range of motion findings included right knee flexion to 140 degrees or greater and right knee extension to 0 degrees (each without objective evidence of pain), left knee flexion to 120 degrees (with objective evidence of pain at 110 degrees), and left knee extension to 10 degrees (with objective evidence of pain at 5 degrees), with no additional loss in range of motion upon repetition. The examiner indicated there was less movement than normal and pain on movement in the left knee, but no functional loss in the right knee. Muscle strength and instability tests were normal bilaterally, with no evidence of recurrent patellar subluxation or dislocation or any tibial or fibular impairment. The examiner noted the Veteran's bilateral meniscus (semilunar cartilage) condition resulted in meniscal tear, frequent episodes of joint locking, and frequent episodes of joint pain; however, effusion into the joint was not indicated for either knee. Diagnostic x-rays did not document arthritis, but the examiner noted functional impact upon the Veteran's ability to work in that he experienced increased pain with physical activity and was limited to walking two blocks during flare ups. Upon additional VA examination the following month in December 2012, the Veteran reported right knee locking, popping, swelling, and increased pain, with flare ups of pain resulting from increased physical activity. Initial range of motion findings included right and left knee flexion to 140 degrees or greater (with objective evidence of pain at the endpoint) and right and left knee extension to 0 degrees (without objective evidence of pain), with no additional loss in range of motion upon repetition. The examiner indicated there was pain on movement bilaterally. Muscle strength and instability tests were normal bilaterally, with no evidence of recurrent patellar subluxation or dislocation or any tibial or fibular impairment. There was no x-ray evidence of arthritis, and the examiner noted functional impact upon the Veteran's ability to work in that he had to climb a ladder repeatedly more slowly. Upon private examination in December 2012, the Veteran's left knee was slightly more edematous than the right, with bilateral crepitus, left knee severe lateral collateral ligament laxity and pain, and right knee moderate medial and lateral collateral ligament laxity. Range of motion findings included left knee flexion to 108 degrees, left knee extension to -27 degrees, right knee flexion to 18 degrees, and right knee extension to -24 degrees. The Veteran did not display decreased strength in his lower extremities, but he was noted to ambulate with an antalgic gait, favoring the left leg. During an April 2014 VA examination, the Veteran reported that his right and left knee disabilities had gotten worse, including flare ups that impaired his ability to perform physical activities such as squatting and walking. Initial range of motion findings included right knee flexion to 115 degrees and left knee flexion to 105 degrees (each with objective evidence of pain at the endpoint), and right and left knee extension to 0 degrees (each without objective evidence of pain), without additional loss in range of motion upon repetition. The examiner noted additional limitation of function during flare ups or with repeated use over time; however, the examiner was unable to estimate the degree of additional loss of range of motion as the Veteran was not examined during a flare up. The examiner noted functional loss or impairment including less movement than normal and pain on movement bilaterally. There was bilateral pain to palpation, and muscle strength testing and joint stability testing were normal bilaterally. There was no evidence of recurrent patellar subluxation or dislocation, any tibial or fibular impairment, or any meniscal conditions. The Veteran reported occasional use of a knee brace for ambulation due to knee pain. Diagnostic knee x-rays were normal, without evidence of arthritis or patellar subluxation. The examiner concluded that the Veteran's knee disabilities resulted in functional impact upon his ability to work, including limitations upon physical activities such as bending of the knees, squatting, and crawling. Given the evidence of record, including as discussed above, the Board finds that the preponderance of evidence weighs against the Veteran's claims of entitlement to an increased disability rating in excess of 10 percent for left knee chondromalacia with patellofemoral pain syndrome and an initial disability rating in excess of 10 percent for right knee patellofemoral pain syndrome for the entire period on appeal. In order to warrant an increased 20 percent disability rating under DC 5260 or DC 5261, the Veteran would have to display limitation of flexion to 30 degrees or limitation of extension to 15 degrees, respectively. See 38 C.F.R. § 4.71a, DCs 5260-61. Notably, however, the probative evidence of record, including as discussed above, does not document that the Veteran's bilateral knee disabilities have resulted in the required severity of limitation of flexion or extension; as such, the application of DCs 5260-61 does not warrant increased disability ratings for his bilateral knee disabilities. The Board is aware that the clinical findings in the December 2012 private examination showed a finding that the Veteran had "-27 degrees of extension," "18 degrees flexion [in the right knee]," and "-24 degrees on extension." Such ranges are inconsistent with other evidence of record, such as the December 2012 and April 2014 VA examinations. The Board finds that the preponderance of the evidence does not establish that the Veteran's extension in the left knee has been worse than 10 degrees or that the flexion in the left knee has been to 30 degrees or less to warrant a separate compensable rating for limitation of flexion. As to the right knee, the preponderance of the evidence is against a finding that the Veteran's flexion and extension have reached a compensable level under either DC 5260 or 5261 to warrant separate ratings for each range of motion. The Board has also considered whether an increased disability rating is warranted under alternate diagnostic codes regarding disability of the knee. For an increased rating of 20 percent under DC 5003, there must be x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5003. (emphasis added). The Board points out that for the purpose of rating disability from arthritis, the knee is considered one major joint. 38 C.F.R. § 4.45. Moreover, repeated diagnostic x-rays throughout the appeal period failed to document evidence of arthritis. Further, the evidence of record does not document any incapacitating episodes due to the Veteran's bilateral knee conditions. Therefore, increased 20 percent disability ratings are not warranted under DC 5003 for either knee disability. To the extent that the November 2012 VA examiner indicated that the Veteran's bilateral meniscus (semilunar cartilage) condition resulted in meniscal tear, frequent episodes of joint locking, and frequent episodes of joint pain, the Board notes that such findings are inconsistent with the additional evidence of record, including the subsequent April 2014 VA examination which found no meniscal conditions in the Veteran's knees; therefore, they are of limited probative value in the context of the Veteran's increased rating claims. See Caluza v. Brown, 7 Vet. App. 498 (1995). Moreover, to warrant an increased 20 percent disability rating under DC 5258 for dislocated semilunar cartilage, there must be frequent episodes of "locking," pain, and effusion into the joint. See 38 C.F.R. § 4.71a, DC 5258 (emphasis added). As the rating criteria are written in the conjunctive, all of the criteria must be met. See Melson v. Derwinski, 1 Vet. App. 334 (June 1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). Therefore, because the November 2012 VA examiner did not find effusion into either knee, an increased 20 percent disability rating is not warranted for either knee under DC 5258. Similarly, to the extent that the December 2012 private examination documented bilateral lateral collateral ligament laxity, such findings are inconsistent with the contemporaneous VA examination of that same month, as well as the subsequent April 2014 VA examination, which both failed to document findings of bilateral knee instability. See id. The Board finds that the preponderance of the evidence is against a finding that the left and right knees have recurrent subluxation or lateral instability. Moreover, the additional evidence of record does not otherwise document or suggest that the Veteran has bilateral knee ankylosis, recurrent subluxation or lateral instability, dislocation of the semilunar cartilage (meniscus), symptomatic removal of semilunar cartilage, current impairment of the tibia and fibula, or genu recurvatum. As such, the Board concludes that DCs 5256, 5257, 5258, 5259, 5262, and 5263 are not for application. 38 C.F.R. § 4.71a, DCs 5256-63 (2017). The Board has also considered the Veteran's reports of painful motion in his bilateral knees; however, such reports are appropriately contemplated by the currently assigned 10 percent disability ratings. Mitchell, 25 Vet. App. 32. In sum, the preponderance of evidence of record weighs against the Veteran's claims of entitlement to an increased disability rating in excess of 10 percent for left knee chondromalacia with patellofemoral pain syndrome and an initial disability rating in excess of 10 percent for right knee patellofemoral pain syndrome for the entire period on appeal. As the preponderance of evidence is against the claims, there is no reasonable doubt to be resolved, and the claims must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2017); Gilbert, 1 Vet. App. 49. III.B. Increased Rating - Tinea Versicolor The Veteran's eczema with folliculitis on the legs, chest, and biceps is rated as noncompensable prior to April 1, 2009 and as 10 percent disabling thereafter under Diagnostic Code (DC) 7806, regarding dermatitis or eczema. 38 C.F.R. § 4.118, DC 7806 (2017). Under DC 7806, a noncompensable disability rating is warranted for dermatitis or eczema affecting less that 5 percent of the entire body or less than 5 percent of exposed areas, and; no more than topical therapy required during the past 12-month period. Id. A 10 percent disability rating is warranted for dermatitis or eczema affecting at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas, or; requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. Id. A 30 percent disability rating is warranted for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or; requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period. Id. A maximum schedular 60 percent disability rating is warranted for dermatitis or eczema affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or; requiring constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. Id. Alternatively, the condition is to be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801-05), depending upon the predominant disability. Id. Turning to the relevant evidence of record, upon VA examination in December 2012, the Veteran reported that his service-connected tinea versicolor had worsened and spread down his arms, torso, and pubic region, and that his condition was very noticeable in the summertime. The examiner noted that his condition had required oral medication (Diflucan) and topical medication (Selsun shampoo) each for less than 6 weeks over the past 12 months, without the use of systemic corticosteroids or other immunosuppressive medications or any resulting debilitating or non-debilitating episodes. Upon physical examination, the Veteran's skin infections were noted to affect at least 5 but less than 20 percent of his total body area and no exposed areas. The examiner further concluded that the Veteran's skin condition did not result in functional impact upon his ability to work. Upon private examination in December 2012, the Veteran reported that he would see temporary improvement in his skin rashes after oral treatments, but that his itchy rash would return after approximately one month of being off the antifungal medication. A physical examination revealed a faint pink, patchy rash on the Veteran's upper torso which was consistent with actinia versicolor infection. The physician noted the rash was worse on the left posterior shoulder region and became sparser toward the lower torso. During an April 2014 VA skin examination, the Veteran reported that his skin rash, diagnosed as tinea versicolor, had gotten worse. The VA examiner noted that his skin condition had required oral medication for less than 6 weeks of the past 12 months and constant or near-constant use of topical corticosteroids, but he had not had any debilitating or non-debilitating episodes in the past 12 months. A physical examination revealed that the Veteran's skin infection affected less than 5 percent of the Veteran's total body area and no exposed areas. The examiner concluded that the Veteran's tinea versicolor of the chest and arms did not result in any functional impact upon his ability to work. Given the evidence of record, including as discussed above, the Board finds that the preponderance of evidence weighs against the Veteran's claim of entitlement to an initial disability rating in excess of 10 percent for tinea versicolor. In order to warrant an increased disability rating of 30 percent under DC 7806, the Veteran's skin condition would need to affect at least 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or; require systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period. 38 C.F.R. § 4.118, DC 7806. However, the evidence of record, including as discussed above, does not document that the Veteran's tinea versicolor affected the requisite surface area or that the condition required any systemic therapy for any period on appeal. As such, an initial disability rating in excess of 10 percent is not warranted under DC 7806. To the extent that the April 2014 VA examination report documents that the Veteran's skin disability required constant or near-constant use of topical corticosteroids, the Board finds that such treatment does not meet the definition of systemic therapy, as there is no probative evidence that such treatment pertained to the body as a whole or that it was administered on a large enough scale that it affected the body as a whole. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). Additionally, as directed by DC 7806, the Board has also considered whether an increased disability rating is warranted for any period on appeal under DCs 7800-05 regarding disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801-05); however, the Board notes that the evidence of record, including as discussed above, documents that the Veteran's predominant skin disability is most closely approximated by the assigned disability rating under DC 7806 for dermatitis or eczema. See 38 C.F.R. § 4.118, DCs 7800-06. Moreover, the evidence of record does not document that the Veteran's service-connected tinea versicolor has resulted in disfigurement of the head, face, or neck, or scars which warrant an increased disability rating. Id. The Board has also considered the lay evidence of record, which is probative insofar as it describes observable symptomatology, see Layno, 6 Vet. App. at 469; however, such statements are less probative than the objective evidence discussed above regarding the resulting severity of the Veteran's service-connected skin condition. See Jandreau, 492 F.3d at 1376-77. In conclusion, as the preponderance of evidence weighs against the Veteran's claim of entitlement to an initial disability rating in excess of 10 percent for tinea versicolor, there is no reasonable doubt to be resolved, and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. III.C. Increased Rating - Left Palm Neuritis The Veteran's service-connected left palm neuritis is currently rated as 20 percent disabling from June 8, 2012 under DC 8615, regarding neuritis of the median nerve. See 38 C.F.R. § 4.124a, DC 8615 (2017). Notably, for purposes of rating this disability, the evidence of record documents that the Veteran's left side is his non-dominant (minor) side. See 38 C.F.R. § 4.69 (2017). Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at time excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes as noted above will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123 (2017). Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate, incomplete paralysis. 38 C.F.R. § 4.124 (2017). The term "incomplete paralysis" as used therein indicates a degree of lost or impaired function which is substantially less than that which results from complete paralysis of these nerve groups, whether the loss is due to the varied level of the nerve lesion or to partial nerve regeneration. Id. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, such ratings are combined with application of the bilateral factor. Id. Under DC 8615, regarding neuritis of the median nerve, a 20 percent disability rating is warranted for moderate incomplete paralysis on the minor side; a 40 percent disability rating is warranted for severe incomplete paralysis on the minor side; and a maximum schedular 60 percent disability rating is warranted for complete paralysis on the minor side. See 38 C.F.R. § 4.124a, DC 8615. Turning to the evidence of record, upon VA examination in November 2012, the Veteran reported current symptoms including sharp, shooting pains, tingling, numbness, and loss of performance and feeling, in addition to flare ups of increased pain caused by changes in weather, sensitivity, and loss of strength. Upon physical examination, there was no loss of range of motion of any of the Veteran's fingers. The examiner noted functional impact upon the Veteran's ability to work as a mechanic due to nerve damage and pain in his left palm. Upon private examination in December 2012, the Veteran reported ongoing pain in his left palm which radiated to his middle and ring fingers and which limited his ability to perform manual work with his left hand without a glove. The private physician concluded that the Veteran's symptoms, including markedly decreased grip strength in the left hand as compared to the dominant right hand, were consistent with the development of a neuroma in the left hand. A December 2012 VA peripheral nerves examination revealed a diagnosis of residual left palm neuritis, with symptoms including moderate constant pain, moderate paresthesias, and moderate numbness in the left upper extremity. Muscle strength testing revealed slightly diminished (4/5) grip strength and pinch strength (thumb to index finger) in the left hand, without atrophy. Reflex testing was all normal, as was a sensory exam, but for decreased sensation in the left hand and fingers. The examiner identified the affected nerve and corresponding severity as moderate incomplete paralysis of the left median nerve. Additionally, the examiner noted functional impact upon the Veteran's ability to work, including upon physical activity such as lifting, typing, and pull ups. Most recently, upon VA peripheral nerves examination on April 7, 2014, the Veteran's left palm neuritis was found to result in severe constant pain in the left upper extremity, severe paresthesias and/or dysesthesias of the left upper extremity, and severe numbness of the left upper extremity. Muscle strength testing revealed slightly diminished (4/5) grip strength and pinch strength (thumb to index finger) in the left hand, without atrophy. Reflex testing was all normal, as was a sensory exam, but for decreased sensation in the left hand and fingers. The examiner identified the affected nerve and corresponding severity as severe incomplete paralysis of the left median nerve. Additionally, the examiner noted functional impact upon the Veteran's ability to work, including upon physical activity such as lifting heavy items, or gripping and holding objects. Following a review of the evidence of record, including as discussed above, the Board finds that an increased 40 percent disability rating is warranted for the Veteran's left palm neuritis from April 7, 2014, but no sooner. Significantly, prior to April 7, 2014, the probative evidence of record does not document worse than moderate incomplete paralysis of the median nerve on the minor side. As such, the preponderance of the evidence is against the Veteran's claim of entitlement to an increased disability rating in excess of 20 percent for left palm neuritis prior to April 7, 2014. In making this determination, the Board has considered all potentially applicable provisions of the rating schedule, see Schafrath, 1 Vet. App. at 595; however, there is no reasonable doubt to be resolved, and the Veteran's claim must be denied prior to April 7, 2014. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. However, as the April 7, 2014 VA examination clearly documents that the Veteran's left palm neuritis resulted in severe incomplete paralysis, the Board finds that an increased 40 percent disability rating is warranted from that date, but no sooner. See 38 C.F.R. § 4.124a, DC 8615. To this extent only, the Veteran's increased rating claim is granted. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. III.D. Increased Rating - Left Palm Scar The Veteran also claims entitlement to an increased disability rating for his left palm scars, which are currently rated as 10 percent disabling under DC 7804. 38 C.F.R. § 4.118, DC 7804 (2017). In particular, DC 7804 contemplates scars that are unstable or painful: a 10 percent disability rating is assigned for one or two scars that are unstable or painful; a 20 percent disability rating is assigned for three or four scars that are unstable or painful; and a maximum 30 percent disability rating is assigned for five or more scars that are unstable or painful. Id. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id., Note 1. If one or more scars are both unstable and painful, an additional 10 percent is to be added to the evaluation based on the total number of unstable or painful scars. Id., Note 2. Turning to the relevant evidence of record, upon VA examination in November 2012, the Veteran reported painful left palm scars. Upon physical examination, the VA examiner noted the Veteran's five or more scars on his left palm and left wrist were both painful and unstable. A linear scar located on the palmar aspect of the left hand at the mid-palm measured 2.5cm long, while a linear scar at the base of the left middle finger measured 2 cm long. There was no skin breakdown, underlying tissue damage, inflammation, edema, keloid formation, disfigurement, or limitation of motion or function. The examiner noted functional impact upon the Veteran's ability to work in that his scar was constantly tender, which prevented him from grabbing things with his left hand or lifting weights with his left hand. Upon private examination in December 2012, the Veteran reported extreme pain resulting from his left palm scar which limited his ability to do manual work without wearing a glove and resulted in markedly decreased grip strength. A physical examination revealed an 8cm linear scar on the left palm which was minimally raised that caused severe pain with even light touch, such that the Veteran was reluctant to use his left hand and he was unable to fully contract his ring and middle fingers because of the pain in the left palm scar. An additional VA scars examination in December 2012, the VA examiner documented that the Veteran had two painful linear scars on his left palm, each measuring 2 cm in length, which resulted in functional impact upon the Veteran's ability to work in that he was slowed down at work. At an April 2014 VA scars examination, the Veteran reported a painful left palm scar, with tingling and numbness. A physical examination revealed a single linear scar on the left palm measuring 4.5 cm in length. The Veteran's scar did not result in any additional limitation of function, other pertinent physical findings, or functional limitation. Following a review of the evidence of record, including as discussed above, the Board finds that the preponderance of evidence weighs against the Veteran's claim of entitlement to an increased disability rating in excess of 10 percent for his left palm scars. In order to warrant an increased 20 percent disability rating under DC 7804, the probative evidence would need to show at least three or four scars that are unstable or painful. See 38 C.F.R. § 4.118, DC 7804 (2017). While the Board acknowledges that the initial November 2012 scars examination report documents five or more painful and unstable scars on the Veteran's left palm and left wrist, which would otherwise warrant a maximum 30 percent disability rating under DC 7804 in addition to an additional 10 percent rating for scars which are both painful and unstable, the Board finds that the November 2012 VA examination is inconsistent in this regard with the additional evidence of record, including subsequent private and VA examinations; therefore, the November 2012 VA examination report is of limited probative value in the context of the Veteran's increased rating claim for his service-connected left palm scars. Notably, the additional probative evidence of record consistently documents either one or two left palm scars which are both painful, but not unstable. Such evidence warrants a 10 percent disability rating consistent with that which is currently assigned; however, such evidence does not support an increased disability rating for any period on appeal. The Board has also considered the additional rating criteria for scars set forth in 38 C.F.R. § 4.118, DCs 7800, 7801, 7802, and 7805 (2017). However, as explained below, these additional diagnostic codes do not warrant compensable disability ratings for the Veteran's service-connected left palm scars for any period on appeal. First, DC 7800 contemplates scars of the head, face, or neck. 38 C.F.R. § 4.118, DC 7800. As the relevant scars are located on Veteran's left palm, DC 7800 is inapplicable. DC 7801 provides that scars other than on the head, face, or neck that are deep, nonlinear, and cover an area of at least 6 square inches (39 square (sq.) centimeters (cm.)) warrant a compensable evaluation. Id., DC 7801. A deep scar is one associated with underlying soft tissue damage. Id. Notably, the objective evidence of record documents that the Veteran's scars are linear and superficial; therefore, DC 7801 is not for application. DC 7802 provides disability ratings for scars that cover a surface area of 144 square inches or greater. However, the Veteran's left palm scars do not cover so great an area; therefore, DC 7802 is not for application. Id., DC 7802. Finally, DC 7805 provides that other scars (including linear scars), not otherwise rated under DCs 7800-04, in addition to the other effects of scars which are otherwise rated under DCs 7800-04, are also to be rated based on any disabling effects not provided for by DCs 7800-04. 38 C.F.R. § 4.118, DC 7805. This includes, where applicable, diagnostic codes pertaining to limitation of function. Id. The Board acknowledges that the probative evidence documents that the Veteran's scars have resulted in some limitation of function, including his ability to utilize his left hand for physical activity; however, as discussed above, the Veteran is additionally service-connected for his left palm neuritis, and the Board finds that to assign an additional disability rating based upon limitation of function would constitute impermissible pyramiding with his disability rating for symptomatology related to his left palm neuritis. See 38 C.F.R. § 4.14. In conclusion, the Board finds that that the preponderance of evidence weighs against the Veteran's claim of entitlement to an increased disability rating in excess of 10 percent for his left palm scars for the entire period on appeal. As such, there is no reasonable doubt to be resolved, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102, 4.3; Gilbert, supra. III.E. Increased Rating - Sinusitis The Veteran also claims entitlement to an increased disability rating for sinusitis which is currently rated as 30 percent disabling under DC 6513. 38 C.F.R. § 4.97, DC 6513 (2017). Thereunder, a 30 percent disability rating is warranted for chronic sinusitis with three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Id. A maximum schedular 50 percent disability rating is warranted for chronic sinusitis following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. Id. Turning to the relevant evidence of record, upon VA examination in November 2012, the Veteran reported symptoms including a runny nose, sore throat, and headaches year round. The VA examiner indicated that the Veteran's chronic sinusitis, which affected his maxillary, frontal, and ethmoid sinuses, resulted in chronic sinusitis, episodes of sinusitis, and headaches, in addition to 7 or more non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting in the past 12 months. Notably, the Veteran's condition was not noted to have resulted in near constant sinusitis, incapacitating episodes in the past 12 months, or sinus surgery. The examiner further indicated that the Veteran's sinus condition resulted in functional impact upon his ability to work, including headaches at least twice per week and a blocked nose every other day which required the use of ephedrine nose drops. Upon private examination in December 2012, the Veteran reported that he continued to suffer from persistent nasal congestion, bad breath, yellowish green nasal mucus, and frontal headaches, which required daily use of a neti pot. At an April 2014 VA sinus examination, the Veteran reported current symptoms including sinus congestion, sore throat, itchy and watery eyes, and headaches. His condition required continuous medication for control, including Amoxicillin, Mucinex-D, Flonase, Afrin, and Claritin. The examiner noted that the Veteran's condition had resulted in 7 or more non-incapacitating episodes of sinusitis in the past 12 months, without any incapacitating episodes, and functional impact upon his ability to work due to minor sinus headaches and itchy eyes. Initially, the Board notes that to the extent the relevant VA examinations of record discuss the Veteran's allergic rhinitis condition, the Veteran is already separately service-connected for this condition; moreover, he has not pursued an appeal regarding that disability specifically. As such, the Board has limited its consideration herein to the Veteran's chronic sinusitis disability which is properly on appeal. Following a review of the evidence of record, including as discussed above, the Board finds that the preponderance of evidence weighs against the Veteran's claim of entitlement to an increased disability rating in excess of 30 percent for sinusitis for the entire period on appeal. As noted above, an increased 50 percent disability rating under DC 6513 requires chronic sinusitis following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 38 C.F.R. § 4.97, DC 6513. Significantly, however, the probative evidence of record does not document that the Veteran's chronic sinusitis has required radical surgery or resulted in near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries for any period on appeal. As such, the preponderance of evidence weighs against the Veteran's claim for the entire period on appeal. 38 C.F.R. § 4.97, DC 6513. As such, there is no reasonable doubt to be resolved, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102, 4.3; Gilbert, supra. ORDER Service connection for GERD, to include as secondary to service-connected sinusitis, is denied. An increased disability rating in excess of 10 percent for left knee chondromalacia with patellofemoral pain syndrome is denied for the entire period on appeal. An initial disability rating in excess of 10 percent for right knee patellofemoral pain syndrome is denied for the entire period on appeal. An initial disability rating in excess of 10 percent for tinea versicolor is denied for the entire period on appeal. An increased 40 percent disability rating for left palm neuritis is granted from April 7, 2014, but no sooner. An increased disability rating in excess of 10 percent for left palm scars is denied for the entire period on appeal. An increased disability rating in excess of 30 percent for sinusitis is denied for the entire period on appeal. REMAND After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of the Veteran's claims of entitlement to service connection for sleep apnea, to include as secondary to service-connected sinusitis, and bilateral hearing loss. Specifically, upon remand, the Veteran must be afforded VA examinations regarding his claims of entitlement to service connection for sleep apnea and bilateral hearing loss. VA's duty to assist includes obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2014). Furthermore, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Regarding the Veteran's claim of entitlement to sleep apnea, to include as secondary to service-connected sinusitis, the Board notes that upon private examination in December 2012, the Veteran reported ongoing difficulty sleeping due to his congested nose and sinuses, resulting in daytime fatigue and slowed thinking; he further stated that his wife told him that she had to nudge him when he would stop breathing at night. The private physician ultimately concluded that the Veteran's service-connected chronic sinusitis caused chronic inflammation and swelling of his upper respiratory tract, which caused obstructive sleep apnea. The physician recommended a sleep study and stated the Veteran probably needed a CPAP machine. The Board notes that the December 2012 private nexus opinion is inadequate to warrant a grant of service connection, as it was rendered prior to a diagnosis of sleep apnea was confirmed by diagnostic sleep study. Significantly, however, a subsequent private sleep study in April 2014 confirmed a diagnosis of mild obstructive sleep apnea. As such, the Board finds that the December 2012 private opinion provides at least some indication that the Veteran's sleep apnea may be associated with his service-connected sinusitis in order to warrant a VA examination upon remand. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Regarding the Veteran's bilateral hearing loss claim, a June 2013 VA audiology examination found that the Veteran's hearing was normal bilaterally, with puretone threshold results and Maryland CNC speech recognition scores that did not qualify as disabling per 38 C.F.R. § 3.385 (2017). Notably, however, the June 2013 VA examiner failed to consider positive nexus opinions of record from June 2012 and December 2012. The June 2012 private audiology examination revealed left ear hearing loss based on a 92 percent Maryland CNC speech recognition score and the audiologist opined that such unilateral left ear hearing loss was at least as likely as not related to the Veteran's exposure to hazardous noise during active service. Similarly, a December 2012 private medical opinion concluded that the Veteran's audiogram was consistent with loud noise exposure during active service which resulted in injury to the Veteran's hearing cells and caused hearing loss and tinnitus. Moreover, the Board notes that the Veteran is already service-connected for tinnitus, and the December 2012 private physician opined that the same loud noises that caused the Veteran's tinnitus also caused his hearing loss. Finally, the Board is mindful of the Veteran's September 2017 Board hearing testimony that his bilateral hearing loss has worsened since the June 2013 VA audiology examination. Given all of the above, the Board finds that the Veteran must be afforded a new VA audiology examination upon remand, wherein the VA examiner properly considers all the relevant evidence of record. Barr, 21 Vet. App. at 312. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination regarding his claim of entitlement to service connection for bilateral hearing loss. The Veteran's entire claims file and a copy of this Remand should be made available to and reviewed by the examiner in conjunction with the opinion. All indicated studies should be conducted, including current audiometric testing, and all findings must be reported in detail. Specifically, the examiner must offer an opinion as to whether it is as likely as not (a 50 percent probability or greater) that the Veteran has had a current bilateral hearing loss disability at any time during the pendency of the claim. If the examiner finds that the Veteran has had a current hearing loss disability for any period on appeal, the examiner must also render an opinion as to whether such hearing loss is related to the Veteran's active service, including his reported in-service noise exposure. In rendering the above opinions, the examiner is advised that the mere absence of in-service evidence of a hearing loss disability during service is not fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service. See Hensley v. Brown, 5 Vet. App. 155 (1993). The examiner must also specifically consider and discuss all relevant evidence of record, including the June 2012 and December 2012 private opinions. 2. Schedule the Veteran for a VA examination regarding his claim of entitlement to service connection for sleep apnea, to include as secondary to service-connected sinusitis. The claims file must be made available to the examiner for review. All appropriate testing should be conducted, including a full VA examination of the Veteran. A full and detailed rationale for all opinions, with citation to relevant medical findings or medical authority, must be provided. Specifically, the examiner must offer the following opinions: a) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's sleep apnea disability had its onset during active service, which was from February 2002 to September 2006. b) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's sleep apnea disability is proximately due to his service-connected sinusitis. c) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's sleep apnea disability is aggravated by his service-connected sinusitis. The term "aggravated" refers to a permanent worsening of the underlying condition beyond the natural progression of the disease, as contrasted with temporary or intermittent flare-ups of symptomatology which resolve with return to baseline level of disability. d) If the examiner finds that sinusitis aggravates the Veteran's sleep apnea, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for sleep apnea prior to aggravation. If the examiner is unable to establish a baseline for the sleep apnea prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. In providing the requested opinions, the examiner must also specifically consider and discuss all relevant evidence of record, including the December 2012 private opinion and the April 2014 sleep study. 3. Following the above development, ensure compliance with the above directives and adequacy of any opinion obtained. Take any corrective actions warranted. 4. Thereafter, readjudicate the Veteran's claims of entitlement to service connection for sleep apnea, to include as secondary to service-connected sinusitis, and bilateral hearing loss disability. If any claim remains denied, provide the Veteran and his attorney with a supplemental statement of the case (SSOC) and an adequate opportunity to respond, after which the matters should be returned to the Board for further adjudication, if otherwise in order. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ A. P. SIMPSON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs