Citation Nr: 18142225 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 17-63 660 DATE: October 15, 2018 ORDER Entitlement to service connection for benign paroxysmal positional vertigo, a disorder characterized by syncope and dizziness, is granted. Entitlement to service connection for a headache disorder is granted. Entitlement to service connection for right eye vision loss is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for diabetes mellitus is denied. New and material evidence having not been received; the claim of entitlement to service connection for left eye vision loss is not reopened. New and material evidence having not been received, the claim of entitlement to service connection for a respiratory disorder, to include asbestosis, is not reopened. New and material evidence having not been received; the claim of entitlement to service connection for prostate cancer is not reopened. Entitlement to a rating in excess of 30 percent for bilateral hearing loss is denied. Entitlement to a rating in excess of 10 percent for tinnitus is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include depression and posttraumatic stress disorder, is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to special monthly compensation based on the loss of use of a creative organ is remanded. Entitlement to an earlier effective date for the grant of service connection for bilateral hearing loss is remanded. Entitlement to an earlier effective date for the grant of service connection for tinnitus is remanded. Entitlement to a total disability rating based on individual unemployability is remanded. FINDINGS OF FACT 1. Probative medical evidence indicates that the Veteran has paroxysmal positional vertigo, a disorder characterized by syncope and dizziness, which is either caused or aggravated by service or by service-connected tinnitus. 2. Probative medical evidence indicates that the Veteran has a headache disorder which is caused or aggravated by service-connected tinnitus and otitis media. 3. The preponderance of the evidence is against finding that right eye vision loss was demonstrated during or is related to the Veteran’s active duty service. 4. The preponderance of the evidence is against finding that sleep apnea was demonstrated during or is related to the Veteran’s active duty service. 5. The preponderance of the evidence is against finding that hypertension was demonstrated during or is related to the Veteran’s active duty service, or that it was compensably disabling within one year of separation from active duty. 6. The preponderance of the evidence is against finding that diabetes mellitus was demonstrated during or is related to the Veteran’s active duty service, or that it was compensably disabling within one year of separation from active duty. 7. Entitlement to service connection for left eye vision loss was previously denied in an unappealed July 2014 Board decision. No evidence has been received since the July 2014 Board decision which relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for left eye vision loss. 8. Entitlement to service connection for asbestosis was previously denied in an unappealed February 2009 rating decision. No evidence has been received since the February 2009 rating decision which relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a respiratory disorder, to include asbestosis. 9. Entitlement to service connection for prostate cancer was previously denied in an unappealed August 2012 rating decision. No evidence has been received since the August 2012 rating decision which relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for prostate cancer. 10. Since November 2014, the Veteran’s bilateral hearing loss was not manifested by worse than Level VIII in the right ear and Level I in the left ear, and there is no evidence indicating he met the criteria for an evaluation higher than 30 percent. 11. The Veteran is in receipt of the maximum schedular evaluation assignable for tinnitus.   CONCLUSIONS OF LAW 1. Benign paroxysmal positional vertigo was caused or aggravated by service and by service-connected tinnitus. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 2. A headache disorder was caused or aggravated by service-connected tinnitus and otitis media. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. 3. Right eye vision loss was not incurred or aggravated in service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 4. Sleep apnea was not incurred or aggravated in service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 5. Hypertension was not incurred or aggravated in service, and may not be presumed to have been so incurred. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 6. Diabetes mellitus was not incurred or aggravated in service, and may not be presumed to have been so incurred. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 7. A July 2014 Board decision denying entitlement to service connection for left eye vision loss is final; as new and material evidence has not been received, the criteria for reopening the claim of entitlement to service connection for left eye vision loss have not been met. 38 U.S.C. §§ 5108, 7104; 38 C.F.R. §§ 3.104, 3.156, 20.1100. 8. A February 2009 rating decision denying entitlement to service connection for asbestosis is final; as new and material evidence has not been received, the criteria for reopening the claim of entitlement to service connection for a respiratory disorder, to include asbestosis, have not been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.1103. 9. An August 2012 rating decision denying entitlement to service connection for prostate cancer is final; as new and material evidence has not been received, the criteria for reopening the claim of entitlement to service connection for prostate cancer have not been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.1103. 10. The criteria for a rating higher than 30 percent for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.10, 4.85, Diagnostic Code 6100. 11. The criteria for a rating higher than 10 percent for tinnitus are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321, 4.87, Diagnostic Code 6260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1955 to May 1958. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). To establish entitlement to service connection for a 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—the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and diabetes mellitus or hypertension becomes manifest to a degree of 10 percent within one year from date of termination of active duty, that disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but also for the degree of disability resulting from aggravation of a disability by a service-connected disability. See 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Vertigo (Claimed as Syncope) The Veteran wrote in February 2018 that he had daily episodes of vertigo that lasted for up to 20 minutes, and that he had fainted and fallen when he had episodes of vertigo. The Veteran’s treatment records show that he has had intermittent complaints of dizziness and vertigo since at least the early 1990s. In November 1993, he was treated for dizziness and was diagnosed with vestibular dysfunction. In March 1995, the Veteran reported that his vertigo had worsened so that he now had “drop attacks,” which were found to be consistent with Meniere’s disease. He underwent right endolymphatic sac decompression surgery. In June 2010, he reported having vertiginous episodes which were initiated by turning to the right. He was diagnosed with Meniere’s disease status post endolymphatic decompression with continued positional vertigo. Physician H.S. submitted a letter in March 2018 which discussed the relationship between the Veteran’s benign paroxysmal positional vertigo and his service-connected tinnitus and military service. H.S. wrote that the Veteran’s benign paroxysmal positional vertigo resulted from loose debris that collects within a part of the inner ear and from degeneration of inner-ear hair cells. He wrote that extreme noise exposure would greatly impact these inner hair cells, and therefore noise exposure in service would aggravate the degeneration of hair cells. He concluded that benign paroxysmal positional vertigo was as likely as not caused by noise exposure in service. Physician H.S. also wrote that tinnitus as likely as not permanently aggravates benign paroxysmal positional vertigo, because the Veteran’s tinnitus was daily and constant, and further affected the hair cells in the inner ear. The March 2018 private evaluation was provided by a qualified physician who appears to have had an accurate understanding of the Veteran’s medical history and current symptomatology. The physician provided sufficient rationale for his findings, and it is consistent with the other medical evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). There are no other medical opinions of record which are contrary to the findings of the March 2018 evaluation. The Board therefore finds that there is adequate, probative medical evidence indicating that the Veteran has benign paroxysmal positional vertigo which is either caused or aggravated by service or by his service-connected tinnitus. Hence, reasonable doubt is resolved in the Veteran’s favor, and entitlement to service connection for benign paroxysmal positional vertigo is granted. See Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) (“By requiring only an ‘approximate balance of positive and negative evidence’ the Nation, ‘in recognition of our debt to our veterans,’ has ‘taken upon itself the risk of error’ in awarding... benefits.”). Headaches The Veteran also contends that he has headaches which are caused or aggravated by his service-connected tinnitus and otitis media. The Veteran wrote in February 2018 that he had prostrating headaches two to three times a week, and that he had to lie down in a dark room for up to two hours before the pain started to alleviate. The Veteran has submitted a March 2018 Disability Benefits Questionnaire completed by Dr. H.S. The Veteran reported experiencing almost daily prostrating headache attacks, and said that he had constant ringing in his ears which could become so loud and “obnoxious” it would immediately bring on a headache or exacerbate a headache that was already occurring. Dr. H.S. found that the Veteran had headache pain which was constant, pulsating, and worsened with physical activity. He indicated that it was accompanied by nausea, vomiting, sensitivity to light and sound, changes in vision, and dizziness. He wrote that the Veteran had prostrating attacks of headache pain two to four times per week lasting two to three hours at a time. H.S. wrote that it was known that damage to the auditory system resulting in tinnitus can also cause headaches, and that patients with tinnitus have strongly correlated frequency of headaches. He also wrote that research showed that patients with otitis media often have headaches as an associated symptom. Dr. H.S. concluded that it was as likely as not that the Veteran’s headaches were aggravated by his service-connected tinnitus and otitis media. The Board accepts the March 2018 private evaluation as probative medical evidence, as it was provided by a qualified physician with an accurate understanding of the Veteran’s medical history and current symptomatology, and had an adequate rationale for its findings. See Prejean, 13 Vet. App. at 448-49 (2000). There are no other medical opinions of record which are contrary to the findings of the March 2018 evaluation. The Board therefore finds that there is probative medical evidence indicating that the Veteran has a current headache disorder which was caused aggravated by his service-connected tinnitus. Reasonable doubt is resolved in the Veteran’s favor, and entitlement to service connection for a headache disorder is granted. See Wise, 26 Vet. App. at 531. Right Eye Vision Loss The Veteran contends that he has a right eye vision loss which was caused by his military service. The Veteran’s service treatment records show that at his January 1955 enlistment examination, his left eye showed slight corneal cloudiness, but there was no mention of any right eye irregularity. Distant vision was 20/20. At a September 1955 eye examination, the Veteran’s right eye vision impairment was correctable to 20/20. In July 1957, an eye examination found an old interstitial keratitis which was inactive, but it did not specify for which eye. In December 1957, the Veteran was treated for getting “gunk” from a spray gun in his eyes while working in the paint shop. He was diagnosed with chemical conjunctivitis. At the Veteran’s April 23, 1958 separation examination, the appellant was noted to have defective visual acuity, which was bilaterally 20/30, but correctable to 20/20 by lens. In the years after his military service, the Veteran has had ongoing problems with his eyes. In July 1972, the Veteran reported that somebody had hit him in the eye. He reported having past vision problems, and was found to have bilateral corneal staining and old corneal scarring. In August 1972, the Veteran had right eye vision of 20/30. In November 1979, the Veteran was treated for bilateral corneal opacities. In January 1980, he was found to have corneal dystrophy and presbyopia. December 1983 visual field testing showed some visual field impairment. The Veteran has continued to receive treatment for decreased vision in both eyes since. In August 1989 he was noted to have corneal scars. At a December 1989 eye evaluation, the Veteran reported having tearing in his right eye when reading. He was found to have right eye vision of 20/50. In August 1992, he was treated for bilateral decreased visual acuity with corneal opacities. In June 2003, the Veteran underwent a phacoemulsification procedure with insertion of posterior chamber intraocular lens of the right eye for treatment of visually significant cataract. Since that surgery, the Veteran’s VA treatment records show continuing treatment for mild atrophy, pseudophakia, and keratopathy. A medical opinion was obtained in February 2014. The examiner wrote that the Veteran had glaucoma affecting both eyes. The examiner said that the glaucoma was not congenital; it did not manifest during service and was not related to service. She wrote that the etiology of the corneal scars noted in the Veteran’s service treatment records were not confirmed, although it could be congenital or due to a disorder such as syphilis, or rheumatoid arthritis. She wrote that the Veteran’s entrance examination in 1955 noted left eye slight corneal cloudiness, but that he had 20/20 vision in both eyes and no claimed eye problems at the time of separation from service. She also acknowledged the Veteran’s chemical conjunctivitis in 1957, but wrote that this had resolved and there was no worsening of the condition noted when he exited service. The February 2014 examiner wrote that it was impossible to specifically delineate whether the Veteran’s corneal scarring was a congenital disease or not due to the lack of a specific etiology for the clouding/scarring the Veteran had, but that it was clear that the left corneal scarring present at entrance into service did not have any deterioration during service. She wrote that the Veteran’s cataracts were not manifested in service, that they were age related and not due to service. The Board has considered all of the evidence of record and finds that the preponderance of the evidence is against finding that the Veteran has a right eye vision loss disorder which is related to service. There is no evidence indicating that the Veteran had any preexisting right eye disorder prior to his service, as the entrance examination indicates only left eye cloudiness, and his right eye vision was 20/20. See 38 C.F.R. § 3.306. While the February 2014 VA examiner stated that it was not possible to determine whether the Veteran’s corneal scarring was a congenital disorder, and the appellant was later found to have bilateral corneal scarring, the Board finds that the probative medical evidence preponderates against finding that right eye corneal scarring was manifested prior to 1972, i.e., many years after the Veteran’s separation from service 1958. There is also no evidence indicating that the Veteran had any congenital right eye disorder at his entrance into service upon which a disease or injury was superimposed. See 38 C.F.R. §§ 3.303(c), 4.9. The preponderance of the medical evidence also indicates that the Veteran’s right eye vision loss was not related to any disease or injury in service. The Veteran is competent to report his observable symptoms and experiences, such as being sprayed in the eyes with chemicals. See Layno v. Brown, 6 Vet. App. 465 (1994). This incident is also recorded in the service treatment records as an accident from being sprayed in the eyes in the paint shop in December 1957. While the Veteran has argued that his vision decreased after this incident in 1957, the preponderance of the medical evidence of record is against such an assertion regarding any decrease in visual acuity. The Veteran’s vision at the time of his separation from service was still correctable to 20/20. The February 2014 VA examiner also considered this event, and concluded that the Veteran’s chemical conjunctivitis from this incident had resolved and there was no worsening of the condition noted when he exited service. There is no competent medical evidence indicating that this event resulted in any permanent damage to the Veteran’s eyes or that it was the cause of his subsequent development of other eye disorders, such as cataracts and glaucoma. The Board finds the service treatment records and the opinion of the February 2014 VA examiner more probative than the Veteran’s recollections of having decreased vision many decades ago. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than history as reported by a claimant). The evidence also preponderates against finding that the Veteran’s glaucoma and cataracts are related to his military service. The Veteran’s glaucoma and cataracts did not manifest in service or for many years thereafter. In this regard, the Veteran’s service treatment records show his relevant body systems were normal at separation, with the exception of decreased visual acuity. The post-service evidence shows that both disorders were diagnosed many years after service, and the Veteran has not contended otherwise. The February 2014 VA examiner indicated that the Veteran’s cataracts were age-related and opined that his glaucoma manifested many years after service and would not be caused by the mild in-service chemical conjunctivitis. There are no contrary medical opinions of record as to the nature of the Veteran’s cataracts and glaucoma. The remainder of the medical evidence does not suggest a link between any post-service right eye problem and service. The Board has considered the Veteran’s contentions. To the extent the Veteran has opined that his current eye disorders affecting his vision are related to his active service, including the in-service chemical conjunctivitis, even assuming he is competent to opine on this matter, the Board finds that the specific, reasoned opinion of the VA examiner is of greater probative weight than the more general lay assertions in this regard. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In summary, the most probative evidence of record shows that the Veteran did not have a right eye disorder which preexisted his service, and he does not have a current right eye disorder which is the result of active duty service, including the in-service chemical eye injury. Based on the foregoing, the Board finds that the weight of the evidence is against the Veteran’s claim. As such, the benefit of the doubt rule does not apply, and the claim is denied. See 38 U.S.C. § 5107(b). Sleep Apnea The Veteran claims entitlement to service connection for sleep apnea. The Board has reviewed the evidence of record, but finds that entitlement to service connection for sleep apnea is not warranted. There is absolutely no evidence of record indicating that any of the elements necessary to establish service connection are met. See Shedden, 381 F.3d 1163, 1167. There is no evidence of any in-service injury or disease related to sleep apnea. The Veteran’s April 1958 separation examination showed that physical evaluation was entirely normal. There is also no medical evidence indicating that the Veteran has a current disability due to sleep apnea. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Degmetich v. Brown, 104 F. 3d 1328 (1997). The Veteran’s VA treatment records are silent for any complaints or treatment related to sleep apnea. On several occasions, the Veteran reported to his treating physician that he slept well, and did not have any trouble falling asleep, staying asleep, or sleeping too much. While the Veteran has home oxygen which he uses at night, the records indicate that this is due to treatment for chronic obstructive pulmonary disease, and not for sleep apnea. There is also no medical evidence linking any current sleep apnea or other sleep related disorder to service, and the Veteran has not submitted any argument or other evidence indicating why he believes he has a sleep disorder, to include sleep apnea, which is related to his military service. The Board therefore finds that all required elements to establish the claim are lacking, and there is no basis upon which service connection could be granted. For the foregoing reasons, the preponderance of the evidence is against the claim of entitlement to service connection for sleep apnea. The benefit of the doubt doctrine is therefore not for application, and the claim is denied. See 38 U.S.C. § 5107(b). Hypertension The Veteran has submitted a claim of entitlement to service connection for hypertension. The Veteran’s current VA treatment records show that he has been diagnosed with hypertension, and he therefore has a current disability. The preponderance of the evidence, however, is against finding that hypertension is related to his active duty service. The Veteran’s service treatment records do not show hypertension in service. His blood pressure at his April 1958 separation examination was within normal limits at 120/60. The Veteran’s VA treatment records do not show any treatment for hypertension until many years after his military service, and there is no evidence of any continuity of symptomatology of a chronic condition from the time of service to the present. At a July 1984 VA examination, the Veteran denied any history of high blood pressure, and his blood pressure was 130/70. A December 1992 eye examination noted no hypertension. The Veteran’s VA treatment records do not show a diagnosis of hypertension until 2002, which is approximately 47 years after his separation from service. There is also absolutely no competent medical evidence linking the Veteran’s hypertension to any disease or injury in service. To the extent that just by submitting a claim of entitlement to service connection for hypertension, the Veteran is asserting that he believes his hypertension is related to his service, the Board finds that this assertion has no probative value. The Veteran, as a layperson, is not shown to possess appropriate medical training and expertise in order to render a competent medical opinion on the etiology of a condition such as hypertension. See Jandreau, 492 F.3d at 1377. There is no medical evidence indicating that the Veteran’s hypertension was compensably disabling within one year of separation from active duty or that hypertension is related to his military service. This evidentiary deficiency concerning the nexus element is fatal to the claim. See Watson v. Brown, 4 Vet. App. 309, 314 (1993). In the absence of any evidence even suggesting that the Veteran’s hypertension began in service or within one year after service, or that his current hypertension is related to a disease or injury in service, there can be no basis for which service connection is warranted. The preponderance of the evidence is against finding that the Veteran’s hypertension is related to service or that it was compensably disabling within one year of separation from active duty. The preponderance of the evidence is against the appellant’s claim, and the doctrine of reasonable doubt does not apply. See 38 U.S.C. § 5107(b). Diabetes Mellitus The Board also denies entitlement to service connection for diabetes mellitus. The Veteran’s VA treatment records show that he has been diagnosed with diabetes mellitus, which he controls through diet and medication. It is therefore demonstrated that he does have a current disability. There is, however, absolutely no competent evidence indicating that diabetes mellitus began in service or that it is related to any disease or injury in service. The Veteran’s service treatment records do not show any complaints or treatment related to diabetes mellitus, and his April 1958 separation examination showed that physical evaluation was entirely normal. There is neither evidence indicating that diabetes mellitus was compensably disabling within one year of separation from active duty, nor has the Veteran asserted that it did. There is neither competent medical evidence relating the Veteran’s diabetes mellitus to his service in any way, nor is there any evidence indicating that the Veteran had chronic symptoms of diabetes mellitus from the time of service to the present. The Veteran has not submitted any lay statements explaining why he believes that his diabetes mellitus began in service or is related to his military service, nor has he or his representative submitted any argument pertaining to this issue at all. To the extent that the submission of the claim demonstrates the Veteran’s belief that his diabetes mellitus is related to service, this assertion has no probative value, as the Veteran is a lay person who lacks the training and expertise to render a competent medical opinion. See Jandreau, 492 F.3d at 1377. There are no medical opinions which indicate any nexus between the Veteran’s diabetes mellitus and his service. This evidentiary deficiency concerning the nexus element is fatal to the claim. Watson, 4 Vet. App. at 314. None of the medical evidence of record includes any indication that the Veteran’s diabetes mellitus was caused by service or is related to any disease or injury in service, and diabetes mellitus did not manifest until several decades after the Veteran’s service. The Board finds that the preponderance of the evidence is against finding that the Veteran’s diabetes mellitus is related to service, and there is no competent evidence indicating that diabetes mellitus was compensably disabling within one year of separation from active duty. The Board has again considered the doctrine of reasonable doubt; as the preponderance of the evidence is against the appellant’s claim, the doctrine does not apply. See 38 U.S.C. § 5107(b).   New and Material Evidence A previously denied claim may be reopened by the submission of new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Evidence is new if it has not been previously submitted to agency decision makers. Id. Evidence is material if it, either by itself or considered in conjunction with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. The phrase “raises a reasonable possibility of substantiating the claim” is meant to create a low threshold that enables, rather than precludes, reopening. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For purposes of determining whether new and material evidence has been received to reopen a finally adjudicated claim, the evidence will be presumed credible. See Kutscherousky v. West, 12 Vet. App. 369, 371 (1999). Left Eye Loss of Vision The Veteran requests to reopen the claim of entitlement to service connection for left eye loss of vision. Left eye vision loss was denied in an October 2011 rating decision. The claim was denied because the evidence showed that vision loss in the left eye was due to injury existed prior to service, and the evidence did not show that the corneal cloudiness and old interstitial keratitis was permanently worsened as a result of service. In March 2012, the Veteran requested that the claim of entitlement to service connection for left eye vision loss be reopened, and this request was accepted as an appeal of the denial for entitlement to service connection for left eye vision loss. In a July 2014 Board decision, the Board found that left eye corneal cloudiness, which preexisted his military service, was not aggravated during his active service, and a left eye disorder other than preexisting cloudiness did not manifest during or was otherwise related to active service; the claim was denied. The Veteran did not appeal the July 2014 Board decision, and it is final. See 38 C.F.R. § 20.1100. The evidence at the time of the July 2014 Board decision included the Veteran’s September 1955 entrance examination, which noted slight corneal cloudiness in the left eye. The Veteran was found to have visual impairment in service, but it was correctable to at least 20/30 with lenses. The record also contained extensive medical records showing a long history of eye problems dating back to at least 1970. At a July 1984 VA examination, the Veteran was found to have a left eye corneal opacity. In May 2002, the Veteran underwent keratoplasty, cataract extraction, and intraocular lens placement for treatment of left eye corneal opacity and cataract. The record also contained a February 2014 VA medical opinion. The examiner wrote that the Veteran had glaucoma and cataracts that were not related to service, and that the left corneal scarring present at entrance into service did not have any deterioration during service. The Veteran submitted a new claim of entitlement to service connection for vision loss in November 2014. Since the July 2014 Board decision, the Veteran has not submitted any medical evidence or argument addressing whether his left eye vision loss is related to service. The only relevant evidence that has been received since 2014 is additional VA treatment records which show continued treatment for glaucoma, post-keratoplasty. This evidence only establishes that the Veteran continues to have a current diagnosis of a left eye disorder causing vision loss, a fact which was already well established at the time of the July 2014 Board decision. No other evidence has been received which indicates or even suggests that the Veteran’s left eye disorder is related to his service or that he had a preexisting left eye disorder which was worsened by his military service. In sum, the evidence that has been received since the last final decision on the matter is duplicative of other evidence already of record or does not relate to an unestablished fact necessary to substantiate the claim of entitlement to service connection for left eye vision loss. The evidence received since July 2014 is either cumulative, irrelevant, or redundant of the evidence of record at the time of the last final denial, and does not raise a reasonable possibility of substantiating the claim. Thus, new and material evidence has not been submitted and the requirements have not been met to reopen the claim. Respiratory Disorder, to include Asbestosis The Veteran has also requested to reopen a claim of entitlement to service connection for a respiratory disorder. In a June 1990 rating decision, entitlement to service connection for asbestosis of the lungs was denied. The rating decision stated that the Veteran claimed he was treated for shortness of breath in service, but that the only treatment related to the lungs in service was treatment for bronchial pneumonia in March 1956. It noted that an April 1958 chest X-ray was negative, and that there was no showing of asbestos exposure in service. The June 1990 decision also noted that after service, the Veteran worked at the Charleston Naval Shipyard from 1961-1968 and 1975-1984. The Veteran did not appeal the June 1990 rating decision, and it is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. In July 1998, the Veteran again requested entitlement to service connection for asbestosis. He submitted a statement indicating that he had removed insulation with asbestos and worked on repairing brakes lined with asbestos while he was in the service. Entitlement to service connection for asbestosis was denied in a November 1998 rating decision on the basis that there was no record of asbestos exposure in service and the service treatment records showed no findings regarding the claimed disability in service. The Veteran did not appeal the November 1998 rating decision, and it is final. Id. Entitlement to service connection was again denied in a January 1999 rating decision, a July 1999 rating decision, and an August 2003 rating decision. These rating decisions were not appealed, and they are final. Id. A February 2009 rating decision denied entitlement to service connection for asbestosis because no new and material evidence had been received. It stated that although new treatment records had been received, they failed to show that asbestosis was related to military service. The February 2009 rating decision was not appealed, and it is final. Id. In November 2014, the Veteran submitted a new claim of entitlement to service connection for a “respiratory condition.” The Board acknowledges that the prior rating decisions denied claims for “asbestosis,” which is a slightly different characterization than the Veteran’s new claim for “respiratory condition.” The Board finds, however, that this essentially constitutes the same claim as the prior claims submitted by the Veteran. Claims that are based on distinctly and properly diagnosed diseases or injuries must be considered separate and distinct claims for new and material evidence purposes. See Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008). However, when determining whether a new and material evidence analysis is required, the focus of VA’s analysis must be on whether the evidence presented truly amounts to a new claim “based upon distinctly diagnosed diseases or injuries,” or whether it is evidence tending to substantiate an element of the previously adjudicated matter. Velez v. Shinseki, 23 Vet. App. 199, 204 (2009). In this case, the Board finds that the current claim on appeal, which has been characterized in the broadest possible way in order to benefit the Veteran, does not present a distinct disease or injury separate from that which was denied in June 1990, November 1998, January 1999, July 1999, August 2003, and February 2009. The Veteran has, essentially, argued since 1990 that he has a respiratory disorder that was caused by in service exposure to asbestos. While the prior rating decisions denied entitlement to service connection for asbestosis, they did not exclude consideration of other possible diagnoses. The July 1999 rating decision discussed the Veteran’s assertions that he had chronic obstructive pulmonary disease since his release from active duty and the lack of any chronic respiratory condition being diagnosed in service. The Veteran has not submitted any new or different arguments regarding his claimed respiratory disorder, and there is no indication that his current claim is not an identical claim representing the same past assertions that he has a respiratory disorder which was caused by exposure to asbestos in service. The Board finds that this is the same claim that was previously denied, and that new and material evidence is required in order to reopen the claim. The medical evidence in the record at the time of the February 2009 rating decision included a March 1956 service treatment record showing that the Veteran was treated for bronchopneumonia of the right base. He was treated for deep breathing, coughing, sputum, and fever. The record also contained post-service medical treatment records showing a long history of treatment for pulmonary disorders. In July 1980, the Veteran was treated shortness of breath noted to be chronic obstructive pulmonary disease. By 1984, his symptoms had worsened, and in July 1984, the Veteran underwent a chest X-ray and was found to have mild pulmonary emphysema. February and April 1990 chest X-rays showed fibrotic disease, unchanged from 1985. A February 1990 evaluation from Dr. W.V. found that the Veteran had both obstructive lung disease, probably due to emphysema, and possible asbestosis. He noted that the Veteran had worked at the Charleston Naval Shipyard since 1961, and that his job involved a considerable amount of exposure to dusty environments including asbestos dust. The Veteran reported that only late in his employment at the shipyard was respiratory protection provided. He also had a history of smoking from 1959 to 1986. A December 2008 medical opinion was obtained from a physician who reviewed the Veteran’s medical records. He found that if the Veteran had asbestosis, it was not caused by or a result of his three years in the Navy, which had minimal, if any, asbestos exposure. The physician also wrote that it was more likely a result of his 22 years working in a shipyard. Since the February 2009 rating decision, no new medical evidence has been received which indicates that the Veteran has any respiratory disorder which was caused by his military service, including due to any asbestos exposure in service. The only medical evidence that has been received since February 2009 that relates to the claim of entitlement to service connection for a respiratory disorder are VA treatment records. These records show that the Veteran has received treatment for shortness of breath and chronic obstructive pulmonary disease, and that he uses oxygen at home. This demonstrates that the Veteran has a current diagnosis of a respiratory disorder, but this fact was well established by the evidence of record at the time of the February 2009 rating decision. The February 2009 rating decision reviewed private medical records which showed that the Veteran was being treated for breathing problems and had been diagnosed with asbestosis, chronic obstructive pulmonary disease, and asthma. No evidence or argument has been received since February 2009 which indicates that the Veteran has a respiratory disorder which is related to his military service, including whether any respiratory disorder is due to asbestos exposure in service. There is no new and material evidence which would relate to any of the unestablished elements necessary to substantiate the claim, such as evidence of a nexus to service or evidence of a chronic respiratory disorder in service. In sum, the evidence that has been received since the last final decision in February 2009 is duplicative of other evidence already of record or does not relate to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a respiratory disorder, to include asbestosis. The evidence is either cumulative, irrelevant, or redundant of the evidence of record, and does not raise a reasonable possibility of substantiating the claim. New and material evidence has not been submitted, and the requirements have not been met to reopen the claim of entitlement to service connection for a respiratory disorder, to include asbestosis. Prostate Cancer The Veteran first submitted a claim of entitlement to service connection for prostate cancer in March 2012. The Veteran’s treatment records showed that in May 2011, the Veteran was diagnosed with prostate cancer and underwent a radical retropubic prostatectomy. The Veteran attended a VA examination in May 2012. The examiner found that the Veteran had prostate cancer status post prostatectomy with residual erectile dysfunction. Entitlement to service connection for prostate cancer was denied in an August 2012 rating decision. The decision stated that there was no evidence of prostate cancer in service, no documentation that the current diagnosis of prostate cancer was related to military service, and no evidence that prostate cancer was compensably disabling within one year of separation from active duty, and therefore service connection was denied. The Veteran did not appeal the August 2012 rating decision, and it is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. In November 2014, the Veteran submitted a new claim of entitlement to service connection for a prostate condition. The Veteran has not submitted any new evidence or argument pertaining to any prostate disorder since the last final denial in August 2012. No medical opinions have been received which relate prostate cancer to his military service, and there is no medical evidence indicating that prostate cancer was compensably disabling within one year of separation from active duty. The VA treatment records which have been added to the record since August 2012 do not show any further complaints or treatment related to the prostate. They indicate that the Veteran was status post radical prostatectomy in 2011, but medical evidence documenting this surgery was already of record at the time of the August 2012 rating decision. No other evidence or argument has been received since August 2012 which relates in any way to a prostate condition or prostate cancer, and therefore no new and material evidence has been received which could possibly relate to any unestablished element or raise a reasonable possibility of substantiating the claim. The evidence that has been received since the final August 2012 rating decision is duplicative of other evidence already of record or does not relate to an unestablished fact necessary to substantiate the claim of entitlement to service connection for prostate cancer. The evidence does not raise a reasonable possibility of substantiating the claim, and therefore new and material evidence has not been submitted. The requirements have not been met to reopen the claim of entitlement to service connection for prostate cancer, and the claim is denied.   Increased Rating The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If there is a question of 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” whether it is an initial rating case or not. Fenderson v West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Bilateral Hearing Loss The Veteran contends that his service-connected bilateral hearing loss warrants a rating higher than 30 percent. The Veteran was originally assigned a 10 percent evaluation for bilateral hearing loss effective March 13, 1984. This evaluation was increased to 20 percent, effective July 27, 2010, and to 30 percent, effective April 4, 2013. The Veteran submitted the current claim on appeal for an increased rating for hearing loss in November 2014. Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by puretone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85. To evaluate the degree of disability from defective hearing, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. §§ 4.85, Tables VI and VII, Diagnostic Code 6100. An exceptional pattern of hearing impairment occurs when the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). The Veteran attended a VA examination in February 2015. He reported being unable to hear from his right side. Puretone threshold testing showed the following results, in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 30 55 60 55 60 LEFT 100+ 105+ 105 105 105 Speech audiometry revealed speech recognition ability of 94 percent in the left ear, and the right ear could not be tested. The Board acknowledges that the VA examiner appears to have mistakenly switched the puretone test results for the right ear and the left ear, as it was the right ear that the Veteran indicated he could not hear out of and the right ear which could not be tested with speech recognition, while the left ear had quite good speech recognition. While this puts the reliability of the February 2015 examination results in doubt, the Veteran subsequently attended a VA examination in March 2017, and the Board finds no reason to doubt the reliability of the March 2017 results. The Board also notes that regardless whether the puretone results given by the February 2015 VA examiner were accurate, the Veteran had speech recognition ability of 94 percent in the left ear, which would allow for no worse than Level IV hearing in the left ear. Under Table VII, when the better ear is Level IV, the highest rating that can be assigned is 30 percent. 38 C.F.R. § 4.85. At the March 2017 VA examination, the Veteran reported that he could not hear unless he was looking at a person, and that he could hear but could not understand. On the authorized audiological evaluation, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 85 70 55 55 60 LEFT 30 35 40 45 50 The average puretone thresholds were 60 decibels in the right ear and 43 decibels in the left ear. Speech audiometry revealed speech recognition ability of 46 percent in the right ear and 96 percent in the left ear. Applying the findings from the March 2017 examination to Table VI in 38 C.F.R. § 4.85 yields a finding of Level VIII in the right ear and Level I in the left ear. Where hearing loss is at Level VIII in one ear and Level I in the other ear, a noncompensable rating is assigned. Id. The Board notes that while the Veteran has an exceptional pattern of hearing impairment in the right ear, application of Table VIa does not result in any higher evaluation being warranted. 38 C.F.R. § 4.86. The Veteran’s VA treatment records show that the Veteran continued to use hearing aids to assist in his ability to hear. While the Veteran has reported trouble with his hearing, there is no evidence in his treatment records since 2014 which demonstrates clinically measured hearing levels which are any worse than those found on examination in March 2017. The functional effects of hearing loss on the Veteran’s daily life activities and occupational functioning have been discussed by the Veteran at his VA examinations and have been taken into consideration by VA. See 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007). The Veteran has reported having trouble hearing people or understanding what they are saying; this is reflective of the types of functional difficulty that would be expected to be caused by his recorded levels of hearing loss, and is adequately compensated by the 30 percent the Veteran has already been assigned. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (Manifestations such as difficulty hearing speech are the types of difficulties contemplated by the schedular criteria for hearing loss.). Accordingly, the March 2017 VA examination of record is sufficiently in compliance with the provisions of VA regulations, and it is assigned great probative value in determining the Veteran’s level of hearing impairment. The most probative medical evidence as to the nature of the appellant’s hearing loss are the audiometric findings, and those discussed above reveal that the Veteran’s hearing loss does not warrant a rating any higher than the 30 percent already assigned. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; the preponderance of the evidence is against the Veteran’s claim, and the doctrine is not applicable. 38 U.S.C. § 5107(b). Lastly, the Board notes that the question of entitlement to referral for consideration of an extraschedular rating is neither an issue argued by the claimant nor reasonably raised by the record through evidence of the collective impact of the claimant’s service-connected disabilities, and will not be discussed at this time. Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). Tinnitus The Veteran has also requested an increased rating for tinnitus. The Veteran reported at the March 2017 VA examination that sometimes he thought he heard someone talking, but it was actually the ringing in his ears. His VA treatment records show that he has had intermittent complaints of bothersome tinnitus. Tinnitus is evaluated under the criteria of 38 C.F.R. § 4.87, Diagnostic Code 6260, which provides that a single 10 percent rating is assigned for tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note 2. The Veteran is already assigned a 10 percent evaluation, which is the maximum scheduler evaluation for tinnitus. As such, he is not entitled to any higher schedular rating for his tinnitus. The Board acknowledges that the Veteran has also had complaints of headaches and vertigo which are associated with his tinnitus. As was discussed above, these separate symptoms have now been found to be service connected, and the Veteran will receive separate evaluations for these disorders, and they cannot be considered when evaluating the rating for tinnitus. See 38 C.F.R. § 4.14. The symptoms of the claimant’s tinnitus are manifested by frequent ringing in the ears, and these symptoms are accurately reflected by the schedular criteria. Without any evidence reflecting that the Veteran's disability picture is not sufficiently contemplated by the rating schedule, referral for a determination of whether his disability picture requires the assignment of an extraschedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). The record before the Board does not suggest that tinnitus requires frequent hospitalization or causes a marked interference with employment or otherwise suggests that referral for an extraschedular consideration under 38 C.F.R. 3.321 is indicated. The claim is denied. REASONS FOR REMAND Acquired Psychiatric Disorder The Veteran contends that he has an acquired psychiatric disorder which is related to his military service. In November 2014, he submitted a claim of entitlement to service connection for depression. In an April 2014 Statement in Support of Claim for Service Connection for posttraumatic stress disorder, the Veteran wrote that while stationed aboard the USS Leary he was always in fear of his life. The Veteran’s medical treatment records show occasional complaints of nervousness, dating back to March 1976. In August 1981, the Veteran reported feeling anxious, and was found to be having anxiety reaction. The Veteran’s more recent VA treatment records show that he has been diagnosed with a cognitive disorder, not otherwise specified. While the Veteran has not provided any specific stressor information which could support a diagnosis of posttraumatic stress disorder, he has asserted that he has depression, and indicated that it could be related to fears he experienced while in the service. The Veteran has also submitted an article called “Psychological and Audiological Correlates of Perceived Tinnitus Severity” indicating a relationship between tinnitus and psychological issues. The Board will therefore accept that the Veteran may have a psychiatric disorder which possibly could be related to service or to his service-connected tinnitus. As the Veteran has not yet been afforded a VA psychiatric examination, the issue is remanded so that an examination and opinion can be obtained prior to further adjudication. Erectile Dysfunction and Loss of Use of a Creative Organ The Veteran has asserted that he has erectile dysfunction caused, in part, by the medication that he takes to treat his psychiatric disorder. Because entitlement to service connection for an acquired psychiatric is being remanded for an examination, the Board finds that these issues are intertwined with the remanded issue and must also be remanded at this time. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Total Disability Rating Based on Individual Unemployability When entitlement to a total disability rating based on individual unemployability is raised in connection with an increased rating claim for one or more of those service-connected disabilities, the Board has jurisdiction over the issue because it is part of the claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran has submitted evidence indicating that his service-connected hearing loss and tinnitus have rendered him unable to maintain gainful employment and argued that he is entitled to a total disability rating based on individual unemployability. Thus, the claim is included in the current appeal. This issue is remanded in order to provide the Veteran with adequate notice regarding this claim and the opportunity to provide additional information regarding his dates of employment. Earlier Effective Date Claims In the Veteran’s June 2016 notice of disagreement, he indicated that he disagreed with the effective date of the award for bilateral hearing loss. In the December 2017 Form 9 substantive appeal, the Veteran wrote that he believed he was entitled to an earlier effective date for bilateral hearing loss and for tinnitus. The Board finds that these constitute notices of disagreement with the effective dates assigned for the grants of service connection for bilateral hearing loss and tinnitus, but the claims have not yet been addressed by the agency of original jurisdiction in a statement of the case. See Manlincon v. West, 12 Vet. App 238, 240-241 (1999). These issues are therefore remanded in order to address this procedural deficiency. The matters are REMANDED for the following action: 1. Develop and adjudicate the issue of entitlement to a total disability rating based on individual unemployability. In so doing, VA must notify the appellant and his representative of VA’s duties to notify and assist in the development of that claim and provide him with a VA Form 21-8940. The Veteran should provide information regarding the date that he stopped working full time and what disabilities prevent him from maintaining gainful employment. 2. Issue a statement of the case addressing the claims of entitlement to earlier effective dates for the grants of service connection for bilateral hearing loss and for tinnitus. Thereafter, the Veteran should be given an opportunity to perfect an appeal by submitting a timely substantive appeal. Advise the Veteran and his representative that the Board will not exercise appellate jurisdiction over this claim absent a timely perfected appeal. 3. Schedule the Veteran for a VA psychiatric examination with a psychiatrist or psychologist to determine the nature and etiology of any diagnosed acquired psychiatric disorder. The examiner is to be provided access to all VBMS and Virtual VA/Legacy files. The examiner must specify in the report that these records have been reviewed. The examiner is to provide a detailed review of the Veteran’s pertinent medical history, current complaints, and the nature and etiology of any diagnosed psychiatric disability. The examiner should then address: What are the Veteran’s current psychiatric diagnoses? For each and every psychiatric disorder diagnosed, address whether it is at least as likely as not that the disorder is related to his active military service. Please address the Veteran’s assertions that he feared for his life while serving on the USS Leary. For each and every psychiatric disorder diagnosed, address whether it is at least as likely as not i) caused or (ii) aggravated (worsened beyond the natural progression) by service-connected hearing loss, tinnitus, otitis media, headaches, and/or benign paroxysmal positional vertigo. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 4. If, and only if, the VA psychiatric examiner finds that the Veteran has a psychiatric disorder which is related to his active service, or has been caused or aggravated by a service-connected disability, then obtain a VA medical opinion regarding whether the Veteran’s medications for his psychiatric disorder have caused or aggravated his erectile dysfunction. The examiner is to be provided access to all VBMS and Virtual VA/Legacy files. The examiner must specify in the report that these records have been reviewed. The examiner should then discuss whether it is at least as likely as not that the Veteran’s erectile dysfunction was (i) caused or (ii) aggravated (worsened beyond the natural progression) by medication that he takes for treatment for a psychiatric disorder. It is noted to the examiner that the Veteran has been treated for erectile   dysfunction since before he underwent a radical prostatectomy in 2011, and this should be discussed. DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mary E. Rude, Counsel