Citation Nr: 18141157 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 15-45 913 DATE: October 9, 2018 ORDER 1. Entitlement to service connection for a retinal tear of the right eye is denied. 2. Entitlement to service connection for hearing loss of the left ear is granted. 3. Entitlement to an initial compensable rating for the service-connected lumbar strain prior to August 13, 2018, and more than 10 percent thereafter, is denied. 4. Entitlement to an initial rating more than 30 percent for irritable bowel syndrome (IBS) is denied. REMANDED 1. The issue of entitlement to service connection for a nasal condition, to include sinusitis and nose bleeds, is remanded. 2. The issue of entitlement to an initial rating more than 50 percent for service-connected post-traumatic stress disorder (PTSD) prior to June 17, 2015, and more than 70 percent thereafter, is remanded. 3. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran does not have a current right eye disability. 2. The Veteran has hearing loss of the left ear due to active service. 3. Prior to August 13, 2018, the Veteran demonstrated forward flexion of the lumbar spine to no less than 90 degrees; a combined range of motion of the lumbar spine of no less than 240 degrees; and no evidence of muscle spasms or guarding severe enough to result in abnormal gait or spinal contour. 4. Since August 13, 2018, the Veteran demonstrated forward flexion of the lumbar spine to no less than 80 degrees; a combined range of motion of the lumbar spine of no less than 230 degrees; and no evidence of muscle spasms or guarding severe enough to result in abnormal gait or spinal contour. 5. For the entire period on appeal, the Veteran’s IBS most nearly approximated severe symptoms, including diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right eye disability have not been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. The criteria for service connection for left ear hearing loss have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). 3. The criteria for a compensable rating prior to August 13, 2018, and more than 10 percent thereafter, for the service-connected lumbar strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242 (2017). 4. For the entire period on appeal, the criteria for an initial rating more than 30 percent for IBS have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.114, DC 7319 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1991 to December 1992, from May 1993 to November 2005, and from August 2006 to August 2012. These matters come to the Board of Veterans’ Appeals (Board) on appeal from August 2013, September 2014, January 2015, and July 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Offices (RO) in Roanoke, Virginia and St. Paul, Minnesota. Jurisdiction is currently with the RO in Roanoke, Virginia. The Board notes that the January 2015 and February 2015 rating decisions reconsidered the claims for service connection for a nasal condition and left ear hearing loss, respectively, and continued the denial of those claims. In December 2015, the RO awarded a 70 percent disability rating for PTSD, effective June 17, 2015. However, as this is not a full grant of the benefit sought on appeal, the Board will address this issue below. The Board further notes, in a July 2016 rating decision, the RO granted service connection for obstructive sleep apnea, with a 50 percent disability rating effective April 11, 2013. As this constitutes a full grant of the benefit sought on appeal, and the Veteran has not expressed disagreement with the assigned rating and effective date, this issue is no longer before the Board. Most recently, an August 2018 rating decision awarded a 10 percent rating for the service-connected lumbar strain, effective August 13, 2018. Again, as this does not constitute a full grant of the benefit sought on appeal, this issue remains before the Board. Service Connection Under the relevant laws and regulations, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). In general, service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App 370, 374 (2002). When considering whether lay evidence is competent, the Board must determine, on a case by case basis, whether the Veteran’s disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of psychiatric, respiratory, or orthopedic disorders. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for a retinal tear of the right eye is denied. Service treatment records are silent regarding any in-service injury or treatment of the Veteran’s right eye. Additionally, post-service treatment records do not document any complaints or treatment related to a right eye disability. The Veteran’s March 2015 notice of disagreement indicates that he was treated for a retinal tear in 2000 at Fort Meyer. However, there is no evidence of record to corroborate this report. Although the Veteran may have experienced a retinal tear during service, the evidence shows no current right eye disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (service connection requires a current disability). A current disability is one shown at some time during the period beginning proximate to the date of claim. Romanowsky v. Shinseki, 26 Vet. App. 303 (2013). In this case there is no evidence of a right eye disability since separation from service, nor is there documentation of an injury to the right eye during service. Additionally, the Veteran has not reported any pertinent symptomatology or treatment during the current appeal. There is no evidence of any post-service treatment, nor is there any other evidence to show a current underlying disability. Although the Veteran is competent to report observable complaints, he is not competent to provide a diagnosis to account for such complaints. Rather this question requires medical expertise due to the complex nature of the ophthalmological system. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the preponderance of the evidence is against service connection for a right eye disability. Reasonable doubt does not arise, and the benefit-of-the-doubt doctrine does not apply; the Veteran’s claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for hearing loss of the left ear is granted. Regarding service connection claims for hearing loss, the Board notes that this particular disability is defined by regulation. Specifically, under the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; when the auditory thresholds for at least three of the above frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Additionally, the Board observes that precedential case law provides that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The absence of in-service evidence of hearing loss is not fatal to a claim for service connection. Evidence of a current hearing loss disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. Moreover, to establish service connection for sensorineural hearing loss, the Veteran is not obligated to show that his hearing loss was present during active service. However, if there is insufficient evidence to establish that a claimed chronic disability was present during service or during the one-year presumptive period thereafter, the evidence must establish a nexus between his current disability and his in-service exposure to loud noise. The Veteran seeks service connection for hearing loss of his left ear. He contends that that he was exposed to loud noise while in close proximity to firearms, heavy equipment, and aircrafts during active duty. The October 2014 examiner concluded that the Veteran’s hearing loss was at least as likely as not related to his military noise exposure. He based this opinion on the changes in the Veteran’s hearing ability since separation from service, as well as his reports of noise exposure during active duty. The clinical results of the audiological examinations demonstrate that the Veteran has left ear hearing loss for VA purposes. 38 C.F.R. § 3.385. Thus, the first requirement for the establishment of service connection is established. See Shedden, supra. The Veteran has described the noise exposure he experienced in service. The Board finds no reason to question his account of exposure from noise resulting from being in close proximity to artillery and aircrafts. Thus, exposure to acoustic trauma is conceded. Evidence of a current hearing loss disability and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. As there is a positive opinion of record, the Veteran has credibly reported noise exposure, and a currently diagnosed left ear hearing loss disability for VA benefit purposes is present, all reasonable doubt is resolved in the Veteran’s favor, and service connection for hearing loss of the left ear is granted. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. 1. Entitlement to an initial compensable rating for the service-connected lumbar strain prior to August 13, 2018, and more than 10 percent thereafter, is denied. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2017). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id. (quoting 38 C.F.R. § 4.40). When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Painful motion without functional limitation, however, cannot serve as the basis for a rating more than the minimum. Mitchell, supra. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 10 percent evaluation is assignable to each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. Service connection for the Veteran’s lumbar strain was granted in a July 2016 rating decision, at which time a noncompensable rating was assigned effective August 19, 2013. The Veteran submitted his claim for an increased rating in December 2016, after which an August 2018 rating decision awarded the 10 percent rating, effective August 13, 2018. The criteria for evaluating disabilities of the spine are contained in a General Rating Formula for Diseases and Injuries of the Spine. The formula provides that with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings are assigned: A 10 percent evaluation is warranted when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine greater not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted for forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent rating. Unfavorable ankylosis if the entire spine warrants a 100 percent rating. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. See 38 C.F.R. § 4.71a, DC 5235 to 5242. In addition to the General Rating Formula for Diseases and Injuries of the Spine, intervertebral disc syndrome may be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation. See 38 C.F.R. § 4.71a, DC 5243. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that when intervertebral disc syndrome is productive of incapacitating episodes having a total duration of at least one week but less than two weeks during the past twelve months, a 10 percent rating is assigned. When incapacitating episodes have a total duration of at least two weeks but less than four weeks during the past twelve months, a 20 percent rating is assigned. When incapacitating episodes have a total duration of at least four weeks but less than six weeks during the past twelve months, a 40 percent rating is assigned. When incapacitating episodes have a total duration of at least six weeks during the past twelve months, a maximum 60 percent rating is assigned. Note (1) following 38 C.F.R. § 4.71a, DC 5243 provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) following 38 C.F.R. § 4.71a, DC 5243 provides that if an intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever results in a higher evaluation of that segment. The evidence of record does not show that the Veteran has experienced IVDS requiring bed rest during any period on appeal. As required bed rest is a fundamental element for an evaluation under this section of the rating schedule, and the absence of any prescribed bed rest precludes a rating under these criteria. As such, a rating based on IVDS is not appropriate, and it is therefore more beneficial to evaluate the Veteran’s lumbar spine disability under the General Rating Formula for Diseases and Injuries of the Spine. In December 2015, the Veteran underwent a VA examination for his lumbar spine disability. He reported functional loss related to sitting, walking, running, and standing for prolonged periods of time. However, he denied experiencing flare-ups. Flexion was to 90 degrees, with extension to 30 degrees. Right and left lateral flexion and rotation were all to 30 degrees. There was no pain noted on examination. The Veteran could perform repetitive use testing without additional loss of range of motion. However, the examiner was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time based on the Veteran’s subjective reports of pain. There was no localized tenderness, pain on palpation, guarding, or muscle spasms. Muscle strength testing was normal, with no evidence of muscle atrophy. Additionally, reflex testing was normal and straight leg testing was negative. There was no evidence of radicular pain or radiculopathy. The examiner found no evidence of ankylosis or neurological abnormalities related to the lumbar spine condition. The Veteran did not have IVDS of the lumbar spine, nor did he use any assistive devices. Most recently, in August 2018, the Veteran underwent another VA examination to assess the severity of his lumbar spine disability. He stated that he experienced daily stiffness, as well as difficulty bending over and standing for prolonged periods of time. However, he did not experience flare-ups of the lumbar spine, nor did he report functional loss or impairment. Flexion was to 80 degrees, with extension to 30 degrees. Right and left lateral flexion and rotation were all to 30 degrees. There was no pain noted on examination, or with weight bearing. The Veteran could perform repetitive use testing without additional loss of range of motion. Additionally, the examiner concluded that pain, weakness, fatigability, or incoordination did not significantly limited functional ability with repeated use over time. There was no localized tenderness, pain on palpation, guarding, or muscle spasms. Muscle strength testing was normal, with no evidence of muscle atrophy. Additionally, reflex testing was normal and straight leg testing was negative. There was no evidence of radicular pain or radiculopathy. The examiner found no evidence of ankylosis or neurological abnormalities related to the lumbar spine condition. The Veteran did have IVDS, but had not required prescribed bed rest in the past 12 months. He did not use assistive devices for locomotion. Prior to August 13, 2018, the evidence of record indicates that the Veteran demonstrated forward flexion of the lumbar spine to 90 degrees, with a combined range of motion of 240 degrees. There is no indication that his forward flexion was less than 85 degrees, or that his combined range of motion was less than 235 degrees for this period of time. Although there was reported evidence of pain following repetitive motion, there was no additional limitation of range of motion after three repetitions of motion. Additionally, the December 2015 VA examiner found no evidence of muscle spasms, guarding, or tenderness of the lumbar spine. Thus, the Board finds that Veteran’s lumbar spine disability was not of the severity to warrant a compensable rating for that period of time. Since August 13, 2018, the Veteran has demonstrated forward flexion of the lumbar spine to 80 degrees and combined range of motion of 230 degrees. There is no indication that his forward flexion has been less than 60 degrees, or that the combined range of motion has been less than 120 degrees, since that time. The August 2018 examiner indicated that the decreased ranges of motion did not result in pain and did not contribute to functional loss. Additionally, repetitive use testing did not result in additional loss of range of motion or limited functional ability. There was no evidence of guarding or muscle spasms severe enough to be responsible for abnormal gait or abnormal spinal contour. Specifically, the Veteran did not demonstrate any sign of abnormal kyphosis, reverse lordosis, or scoliosis during this period of time. Therefore, the evidence does not suggest that the Veteran’s lumbar spine disability has been of the severity warranting a rating more than 10 percent since August 13, 2018. The examination reports indicate that the Veteran did not demonstrate additional functional loss or functional impairment after repetitive use or time. Although the December 2015 examiner was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time based on the Veteran’s subjective reports of pain, a higher rating cannot be based on medical speculation and certainly not lay speculation. 38 C.F.R. § 3.102. Neither the Veteran nor the Board can speculate and arbitrarily pick a disability rating; there must be a basis in fact for the assigned rating. Id. Thus, a higher evaluation cannot be awarded based on speculation of additional functional loss during after repetitive use over time. Therefore, the Board finds that such factors do not result in functional loss warranting a higher disability rating for the lumbar spine for either period on appeal. See DeLuca, 8 Vet. App. at 207-08; Mitchell, 25 Vet. App. 32. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must provide opinions regarding flare-ups based upon estimates derived from information procured from relevant sources, including lay statements, when a flare-up is not observable at the time of examination. To the extent the VA examinations reviewed do not include specific findings as required by the Court’s holdings in Sharp, the Board finds that, because flare-ups of the lumbar spine have not been demonstrated by the record or described by the Veteran, additional testing to evaluate the impact of flare-ups and pain on limitation of motion would not avail the Veteran. As noted above, when evaluating the disability rating assignable to a spinal disability, the Board must consider any neurologic abnormalities associated with the spinal disability. At the outset, the Board notes that the Veteran has reported radicular symptoms, including numbness and pain that radiates into his legs. See February 2017 Statement in Support of Claim. However, both VA examiners found no evidence of radicular pain or any signs of radiculopathy. Additionally, there are no reports of symptomatology related to radiculopathy in the remainder of the record. Furthermore, the Veteran has consistently denied any bladder or bowel impairment resulting from his back disability. Based upon the medical evidence of record, the Board finds the preponderance of the evidence does not reflect that the Veteran experiences bladder, bowel, or other objective neurologic abnormalities because of his service-connected lumbar spine disability; thus, a separate compensable rating is not warranted at any point during the appeal period for those considerations. With respect to the period prior to August 13, 2018, the preponderance of the evidence is against a compensable rating because lumbar spine flexion was greater than 85 degrees and the combined range of motion of the lumbar spine was greater than 235 degrees throughout that period of time. 38 C.F.R. § 4.71a, DC 5242. Additionally, the preponderance of the evidence is against a rating more than 10 percent after August 13, 2018, as there is no indication that lumbar spine flexion was limited to less than 60 degrees, or that the combined range of motion of the lumbar spine has been less than 120 degrees. 38 C.F.R. § 4.71a, DC 5242. 2. Entitlement to an initial rating more than 30 percent for IBS is denied. The Veteran also contends that his service-connected IBS is worse than contemplated by the disability rating currently assigned, and asserts that a higher disability rating is warranted for the entire period on appeal. The Veteran is currently in receipt of a 30 percent rating for IBS since March 2, 2012. The Veteran’s IBS is currently rating under DC 7319 for irritable colon syndrome. Under DC 7319, a 0 percent evaluation is assigned for mild disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent evaluation is assigned for moderate IBS, with frequent episodes of bowel disturbance with abdominal distress. A maximum disability rating of 30 percent is warranted for severe IBS productive of diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. Id. The Veteran is also service-connected for gastritis and reflux, esophagitis, and status post-cholecystectomy, under DC 7319. Thus, the Board will evaluate the severity of his symptoms under alternative diagnostic codes relevant to these conditions. DC 7203 provides for a 30 percent rating for moderate stricture of the esophagus. A 50 percent rating is warranted for severe stricture of the esophagus, permitting liquids only. An 80 percent rating is warranted for stricture of the esophagus permitting passage of liquids only, with marked impairment of general health. Under DC 7307, gastritis, hypertrophic (identified by gastroscope), when chronic with nodular lesions, and symptomatic, warrants a 10 percent rating. When chronic, with multiple small eroded or ulcerated areas, and symptoms, a 30 percent rating is warranted. When chronic, with severe hemorrhages, or large ulcerated areas, and symptoms, a 60 percent rating is warranted. 38 C.F.R. § 4.114. DC 7318 provides for a 10 percent rating on removal of the gall bladder with mild symptoms, and a 30 percent rating on removal with severe symptoms. The words “mild,” and “severe” are not defined in the above rating criteria. Rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Regarding coexisting abdominal conditions, VA regulation recognizes that there are diseases of the digestive system, particularly within the abdomen, which differ in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition. 38 C.F.R. § 4.113. Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. Rather, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Board also notes that, regarding the schedule of ratings for the digestive system, section 4.114 expressly prohibits, in pertinent part, the combination of ratings under DCs 7301 to 7329, inclusive, which include the schedular criteria for irritable colon syndrome (DC 7319). In October 2014, the Veteran underwent a VA examination for his esophageal conditions. He reported infrequent episodes of epigastric distress, pyrosis, and regurgitation. He experienced episodes of vomiting on four or more occasions per year, lasting for a duration of 10 days or more. The Veteran did not have an esophageal stricture, spasms of the esophagus, or an acquired diverticulum of the esophagus. In December 2015, the Veteran was given another VA examination for his esophageal conditions. The examiner noted infrequent episodes of epigastric distress. The Veteran did not have an esophageal stricture, spasms of the esophagus, or an acquired diverticulum of the esophagus. Diagnostic testing revealed mild chronic gastritis, with superficial hemorrhages. Additionally, in December 2015, the Veteran underwent a VA examination for his gallbladder condition. He denied experiencing any signs or symptoms attributable to his gallbladder condition, including dyspepsia, attacks of gallbladder colic, or jaundice. Furthermore, there were no symptoms attributable to a pancreas condition, including abdominal pain, weight loss, severe malnutrition, diarrhea, malabsorption, or steatorrhea. The Veteran was also afforded a VA examination for his IBS in December 2015. He reported symptoms including diarrhea, abdominal distention, and nausea. The examiner noted occasional episodes of bowel disturbance with abdominal distress, with one episode of exacerbation in the past year. The Veteran did not have weight loss, malnutrition, or other serious complications related to his IBS. There was no evidence of tumors or neoplasms related to the Veteran’s diagnoses. In January 2016, the Veteran was afforded a VA examination for his stomach and duodenal conditions. He reported experiencing nausea on four or more occasions per year, lasting for a duration of 10 or more days. He also experienced vomiting on four or more occasions per year, for periods lasting between one and nine days. There was no evidence of abdominal pain, anemia, weight loss, hematemesis, or melena. The Veteran had incapacitating episodes of diarrhea with abdominal discomfort four or more times per year, lasting for 10 days or more. There was no evidence of hypertrophic gastritis, postgastrectomy syndrome, vagotomy with pyloroplasty or gastroenterostomy, or peritoneal adhesions. Most recently, the Veteran underwent another VA examination for his digestive conditions in August 2018. He reported experiencing acid reflux episodes between four and five times weekly, lasting for several hours. The examiner noted symptoms including persistently recurrent epigastric distress, pyrosis, reflux, regurgitation, substernal pain, as well as episodes of nausea and vomiting on four or more occasions per year. The Veteran did not have an esophageal stricture, spasms of the esophagus, or an acquired diverticulum of the esophagus. The Veteran also stated that he had four to five bowel movements daily, as well as bloating and abdominal pain. The August 2018 examiner concluded that he had frequent episodes of bowel disturbance with abdominal distress. The Veteran did not have weight loss, malnutrition, tumors, or neoplasms related to his diagnoses. After a review of all evidence, lay and medical, the Board finds that, for the entire initial rating period, the Veteran’s IBS has approximated severe symptoms including alternating diarrhea and constipation with more or less constant abdominal distress, as contemplated by the current 30 percent disability rating under DC 7319. The evidence of record shows that the Veteran’s IBS has manifested as incapacitating episodes of diarrhea with frequent abdominal distress, to include vomiting and nausea. Throughout the appeal period, the Veteran has reported experiencing frequent instances of diarrhea, abdominal distention, nausea, and vomiting. The Board finds that the service-connected IBS has been productive of “severe” symptoms for the entire initial rating period on appeal, as contemplated by the 30 percent disability rating under DC 7319. As 30 percent is the maximum rating available for IBS, the Board concludes that the Veteran is not entitled to any higher rating for the IBS disability under DC 7319 at any relevant time during the appeal period. As noted earlier, 38 C.F.R. § 4.114 sets forth that ratings under DCs 7301 to 7329, 7331, 7342, and 7345 to 7348 will not be combined with each other. A single rating will be assigned under the Diagnostic Code which represents the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such rating. The Board also finds that the evidence does not support a rating more than 30 percent based upon another Diagnostic Code pertaining to abdominal disabilities. As discussed above, the predominant manifestations of the IBS are alternating diarrhea and constipation with abdominal distress. The maximum rating of 60 percent under DC 7346 is authorized for hernia with symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Although the Veteran has reported some instances of vomiting, there has been no evidence of a hernia or material weight loss, hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. There also is no showing of ulcerative colitis as is rated under DC 7323 and, in any event, the next higher rating under DC 7323 contemplates numerous yearly attacks of colitis. Although the Veteran’s diarrhea occurs frequently by his reports to treatment providers, there is no showing of malnutrition, marked or otherwise. Moreover, indicia of general debility, or any serious health complication, are lacking. DC 7332 provides for higher ratings only if there is evidence of complete loss of anal sphincter control or extensive bowel leakage and fairly frequent involuntary bowel movements; this is neither alleged nor shown in this instance. Additionally, as the examination reports consistently found no evidence of an esophageal stricture, let alone a severe stricture or marked impairment of general health, a higher rating under DC 7203 is not warranted. DC 7318 accounts for mild and severe symptoms related to gallbladder removal procedures. However, the Veteran has denied experiencing residuals related to his gallbladder removal, and a 30 percent disability rating is the maximum award available under this code. Thus, an alternative rating under DC 7318 is neither applicable or of any benefit to the Veteran. The Board has also considered whether the Veteran’s symptoms should be rated under DC 7307 for gastritis. The maximum rating of 60 percent under DC 7307 is authorized for chronic gastritis with severe hemorrhages, or large ulcerated or eroded areas. Although the Veteran has been diagnosed with mild chronic gastritis, the evidence of record does not reflect that the Veteran has experienced severe hemorrhages or any ulcerated or eroded areas. Thus, an alternative rating under DC 7307 is not warranted. Therefore, the other Diagnostic Codes regarding abdominal conditions do not afford a basis for the assignment of an initial rating higher than 30 percent in the absence of a showing of the symptoms or findings discussed. See 38 C.F.R. § 4.114, DCs 7301, 7304 -7307, 7332. Accordingly, the Board finds that DC 7319 is the appropriate diagnostic code for evaluating the Veteran’s IBS as the rating criteria expressly take into account the Veteran’s symptomatology. None of the other diagnostic codes for evaluating the digestive system are more appropriate in this case and they do not provide for a higher disability rating for the Veteran’s symptoms. For these reasons, the Board finds that the preponderance of the evidence supports a finding that an initial rating more than 30 percent for IBS is not warranted for the entire period on appeal.   REASONS FOR REMAND 1. The issue of entitlement to service connection for a nasal condition, to include sinusitis and nose bleeds, is remanded. The Veteran underwent a VA examination to evaluate his claimed nasal condition in March 2016. The examiner concluded that there was no objective evidence of a nasal condition at that time. However, the same examination reported noted diagnoses of a deviated nasal septum and chronic sinusitis. As the September 2015 opinion was based on an inaccurate factual basis, the Board finds that a remand for an addendum opinion is warranted. 2. The issue of entitlement to an initial rating more than 50 percent for service-connected PTSD prior to June 17, 2015, and more than 70 percent thereafter, is remanded. A VA treatment record, dated October 2, 2017, indicated that the Veteran’s PTSD appeared to be worsening. Specifically, the treatment provider noted that the Veteran reported suicidal ideation, and stated that he thought about death more frequently. Additionally, in October 2017 letter, a VA treatment provider opined that his PTSD had worsened in severity. Based on the Veteran’s testimony of worsening symptomatology, the medical evidence of record, and the fact that his last VA examination related to his PTSD took place in June 2015, the Board finds that he should be afforded another VA examination to determine the current severity of his service-connected PTSD. 3. The issue of entitlement to a TDIU is remanded. The appeal seeking TDIU is inextricably intertwined with the pending service connection and increased rating claims that have been remanded for further development. Thus, the Board must defer final adjudication of the TDIU issue until the pending rating action has been accomplished by the AOJ. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to defer adjudication of the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to his claims. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained. 2. Arrange for the claims file to be reviewed by a qualified examiner for an addendum opinion regarding the Veteran’s claimed nasal condition. Any additional VA in-person examination is left to the discretion of the examiner. All indicated studies should be conducted and all findings reported in detail. Following a review of the claims file, the reviewing examiner is requested to furnish an opinion with respect to the following questions: (A) The examiner should identify nasal conditions present since the instant claim (i.e. April 2012). (B) The examiner should render an opinion as to whether it is at least as likely as not that any diagnosed nasal condition had its onset or is otherwise medically related to service. A complete rationale for all opinions offered should be provided. 3. Schedule the Veteran for a VA examination by a qualified clinician to determine the severity and extent of his service-connected PTSD. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. A complete rationale for all opinions expressed should be provided. The examiner is specifically asked to address the functional and occupational effect of the Veteran’s PTSD. H. M. WALKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Erin J. Trojanowski, Associate Counsel