Citation Nr: 18143369 Decision Date: 10/19/18 Archive Date: 10/18/18 DOCKET NO. 11-29 819 DATE: October 19, 2018 ORDER The appeal of entitlement for a 10 percent rating based on multiple, noncompensable, service-connected disabilities under 38 C.F.R. § 3.324 is dismissed. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for chest pain due to undiagnosed illness is granted. Entitlement to service connection for eczema, claimed as a skin rash, is granted. Entitlement to an initial compensable rating for residuals of a left eye injury with corneal scar is denied. Entitlement to an initial 10 percent rating for residuals of a left thumb laceration is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to an initial rating in excess of degenerative disc disease of the lumbosacral spine with ankylosing spondylitis (“lumbar spine disability”) is remanded. Entitlement to an initial compensable rating for chronic fatigue syndrome is remanded. Entitlement to an initial compensable rating for irritable bowel syndrome is remanded. Entitlement to an effective date prior to December 14, 2015, for the award of service connection irritable bowel syndrome is remanded. FINDINGS OF FACT 1. The issue of entitlement to a 10 percent rating based on multiple, noncompensable service-connected disabilities has been rendered moot by reason of assignment of a schedular disability rating of at least 10 percent for his service connected disabilities. 2. The Veteran does not currently have sensorineural hearing loss in the right ear or in the left ear to an extent recognized as a disability for VA purposes. 3. Tinnitus did not first manifest during active service and has not been continuous since service separation, and any current tinnitus did not manifest to a degree of 10 percent within one year of service separation and is not etiologically related to service. 4. The Veteran served on active duty in the Southwest Asia theatre of operations during the Persian Gulf War. 5. The Veteran has presented credible complaints of chest pain, which is not attributable to a known clinical diagnosis, and the evidence is in equipoise on whether it is etiologically related to his service in Southwest Asia. 6. The Veteran has a current diagnosis of eczema and the evidence is in equipoise on whether it is etiologically related to service. 7. For the entire period of appeal, the Veteran’s residuals of a left eye injury with corneal scar does not result in field of vision impairment, visual acuity impairment, or incapacitating episodes. 8. For the entire period of appeal, the evidence is in equipoise on whether the Veteran’s left thumb laceration scar causes mild disability. The scar is superficial, linear, and stable, and does not result in limited motion or other functional impairment. CONCLUSIONS OF LAW 1. The criteria for a 10 percent rating for multiple non-compensable service-connected disabilities are not met. 38 U.S.C. § 1155; 38 C.F.R. § 3.324. 2. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385. 3. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for an undiagnosed illness manifested as chest pain are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317. 5. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for eczema, claimed as a skin rash, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 6. The criteria for an initial compensable rating for residuals of a left eye injury with corneal scar are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.79, Diagnostic Code 6099-6009. 7. Resolving all reasonable doubt in favor of the Veteran, the criteria for an initial 10 percent rating for the left thumb laceration are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from August 1983 to January 1993, including service in Southwest Asia. The Board notes that the Veteran appealed issues of entitlement to service connection for fatigue and joint pain, to include as due to an undiagnosed illness. However, in April 2014, during the pendency of appeal, the RO granted service connection for the lumbar spine disability (claimed as joint pain) and chronic fatigue syndrome (claimed as fatigue). Because the Veteran was awarded service connection, these issues are no longer on appeal before the Board. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). The Board remanded the issues of service connection for hearing loss, tinnitus, an acquired psychiatric disorder, a skin disability, and chest pain; a 10 percent rating under 38 C.F.R. § 3.324; and increased initial ratings for the left eye and left thumb scar in August 2015 for further development, including obtaining outstanding treatment records and scheduling the Veteran for VA examinations to determine the nature, etiology, and severity of the claimed disabilities. VA treatment records have since been associated with the claims file, the Veteran was sent a letter in November 2015 advising him to submit any non-VA treatment records, and he had VA examinations for hearing loss, tinnitus, a skin disability, Gulf War illness, left eye, and left thumb in December 2015. The Board therefore finds there has been substantial compliance with the remand directives with regard to the claims for hearing loss, tinnitus, a skin disability, and chest pain; a 10 percent rating under 38 C.F.R. § 3.324; and increased initial ratings for the left eye and left thumb scar. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Stegall v. West, 11 Vet. App. 268 (1998). Dismissal of Appeal 1. Ten percent rating for multiple noncompensable service-connected disabilities. Early in the pendency of this appeal, the Veteran claimed entitlement to a 10 percent rating for multiple noncompensable (zero percent) service-connected disabilities, specifically due to initial noncompensable ratings for his left eye and left thumb disabilities. When a Veteran has two or more separate, permanent, service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree under the rating schedule, the rating agency is authorized to apply a 10 percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324. During the pendency of the appeal, however, the AOJ granted service connection for the lumbar spine disability, assigning a 10 percent rating effective April 22, 2009. The left eye and left thumb disabilities also have an effective date of April 22, 2009. In light of the Veteran’s compensable rating for a service-connected disability, the Board finds that the claim for a 10 percent rating under § 3.324 is now moot as a matter of law and the appeal is dismissed. Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310(a), (b). 2. Service connection for hearing loss. The Veteran contends that he started having hearing loss in his couple years of service due to exposure in Desert Storm to weapons and armory. He wore hearing protection on the gun range, but not in Desert Storm. See the October 2010 DRO hearing transcript. Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified puretone and speech recognition criteria. Audiometric testing measures puretone threshold hearing levels (in decibels) over a range of frequencies (in hertz). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a Veteran has a disability based on hearing loss is governed by 38 C.F.R. § 3.385. For the purposes of applying 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; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 hertz 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. In Hensley, the Court explained that the threshold for normal hearing is from zero to 20 decibels and that higher threshold levels indicate some degree of hearing loss. See 5 Vet. App. at 157. In this case, the Board finds that in-service noise exposure is established. The Veteran can describe being exposed to loud noise, such as those caused by weapons. See Falzone v. Brown, 8 Vet. App. 398, 403 (1995). His lay statements are credible as they have been consistent and are confirmed by the circumstances of his service. The Veteran’s DD Form 214 indicates that he was attached to an Army Forces Command (FORSCOM) and had service in Southwest Asia from December 1990 to May 1991. For these reasons, in-service acoustic trauma to both ears is established. This, however, is not the end of the inquiry. The threshold issue is whether in-service noise exposure resulted in bilateral hearing loss. To that end, the evidence does not show that the Veteran has a bilateral sensorineural hearing loss “disability” that meets the criteria of 38 C.F.R. § 3.385. As discussed above, hearing loss for VA purposes is expressly defined by regulation. In other words, “hearing loss” for VA purposes is different than the colloquial usage of the term “hearing loss,” and it is even potentially different than an assessment of hearing loss disability as might be diagnosed by a competent health care provider. The Veteran was afforded a VA audiological examination in November 2010. The examining audiologist indicated that the Veteran’s responses during the evaluation were inconsistent, and as such, results were not considered to be reliable or to provide an accurate representation of the Veteran’s hearing. In November 2015, the Veteran was afforded another VA audiological examination, which reflected the following puretone thresholds, in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 15 20 25 LEFT 20 20 20 20 25 The Veteran’s speech recognition score using the Maryland CNC Test was 94 percent in his right ear and 96 percent in his left ear. The examiner indicated that the Veteran had normal hearing bilaterally. The Board finds that the weight of the competent and credible evidence shows that the Veteran does not currently have a hearing loss disability in either the right ear or the left ear that meets the criteria of 38 C.F.R. § 3.385, as he does not have an auditory threshold of 40 decibels or greater in either ear, three thresholds that are 26 decibels or greater in either ear, or a speech recognition score of less than 94 percent in either ear. Without competent evidence of a current hearing loss disability, service connection cannot be awarded. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (“In the absence of proof of a present disability, there can be no valid claim.”); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004) (holding that service connection requires a showing of current disability). Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Service connection for tinnitus. The Veteran is considered competent to report the observable manifestations of his tinnitus. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002) (a veteran is competent to testify as to the presence of tinnitus); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). He competently and credibly reports experiencing tinnitus. Accordingly, the Board finds that the threshold element for service connection, a current disability, has been established. However, the evidence of record is insufficient to establish a nexus between current tinnitus and service. STRs do not document any complaints, symptoms, or findings of tinnitus. There is no documented complaint or finding of tinnitus until Veteran’s April 2009 claim for compensation, which was filed 16 years after the Veteran separated from service. Moreover, in the November 2015 VA examination, the Veteran indicated that his tinnitus began in 2010 and attributed it to a sinus problem. The examiner opined that the tinnitus was less likely than not caused by or a result of military noise exposure because of the lack of proximity between the dates of service and reported onset of the tinnitus. In addition, STRs were silent for mention of a complaint of tinnitus. The Board finds the medical evidence generated at the time of the Veteran’s period of service, including the Veteran’s statements and responses on medical questionnaires, to be highly probative. These records were created contemporaneously with the Veteran’s period of service and contain information that is inherently more reliable than that recorded at a later time. Further, while the Veteran has made statements alleging a nexus in connection with his current claim, he has also supplied a somewhat contradictory statement indicating that the tinnitus did not start until 2010 and was due to a sinus problem. Finally, no competent and credible opinion connecting tinnitus to service is offered by any medical professional. The Board recognizes that the Veteran’s belief that his tinnitus his related to service is potentially competent opinion evidence. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the question of a nexus in this case falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Here, the Veteran is not reporting an observed cause and effect relationship; he is noting established facts (noise, current diagnosis) and drawing a reasoned conclusion. Unfortunately, he lacks the specific knowledge and training that would inform such reasoning and permit a competent opinion on the etiology of a disease that arose quite remotely from the potential injury. Moreover, as stated above, he has made somewhat contradictory statements about the onset of his tinnitus, indicating it did not start until 2010 and was due to a sinus problem. In light of the above, the Board finds that the preponderance of the evidence is against a finding that the tinnitus is related to service. As the preponderance of the evidence is against the Veteran’s claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 4. Service connection for chest pain. Service connection may be granted on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 21, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on qualifying chronic disability, unlike those for “direct service connection,” there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). VA is authorized to pay compensation to any Persian Gulf veteran suffering from a “qualifying chronic disability.” For purposes of 38 C.F.R. § 3.317, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (a) an undiagnosed illness; or (b) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; or (3) functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a), (c). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Here, the Veteran had service in the Southwest Asia theatre of operations from December 1990 to May 1991, during the Persian Gulf War. Under 38 C.F.R. § 3.317, “cardiovascular signs or symptoms” is a listed symptom. Moreover, the Veteran is competent and credible to report having chest pain, which constitutes objective indication of a chronic disability due to an undiagnosed illness. In a November 2015 VA examination, the examiner indicated that it was at least as likely as not that the Veteran’s chest pain was related to exposure events experienced during service in Southwest Asia. The examiner noted that the condition was not diagnoseable and the etiology was obscure. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claim. Specifically, a September 2009 VA examiner found that the Veteran did not have chest pain. As such, an additional medical opinion could be obtained to reconcile the potentially conflicting medical evidence. However, under the “benefit-of-the- doubt” rule, where there exists “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993). In this case, the Board finds that there is “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter.” The Veteran qualifies as a Persian Gulf veteran and has presented with chest pain that is not attributable to a known clinical diagnosis. A VA examiner opined that the chest pain was at least as likely as not due to the Veteran’s service in Southwest Asia. As the evidence is in equipoise, and resolving all doubt in favor of the Veteran, service connection for chest pain is warranted as due to an undiagnosed illness pursuant to 38 C.F.R. § 3.317. 5. Service connection for a skin disability. The Veteran has a current diagnosis of eczema. See the December 2015 VA examination report. The Board finds that, in resolving all reasonable doubt in favor of the Veteran, the eczema is due to or related to service. In a December 2015 VA examination, the Veteran reported that his skin problems started with a rash on his anterior chest in service in 1991, which was treated with a skin cream. The rash has since recurred once or twice a year and lasted 2-3 weeks. The examiner indicated that the Veteran had papular pigmented lesions on his chest, but no active lesions. The examiner opined that the skin rash was related to exposure events experienced during service in Southwest Asia. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claim. Specifically, a September 2009 VA examiner found that the Veteran did not have a skin rash. As such, an additional medical opinion could be obtained to reconcile the potentially conflicting medical evidence. However, under the “benefit-of-the- doubt” rule, where there exists “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993). In this case, the Board finds that there is “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter.” The Veteran has a diagnosis of eczema, and a VA examiner opined that it was at least as likely as not due to the Veteran’s service in Southwest Asia. As the evidence is in equipoise, and resolving all doubt in favor of the Veteran, service connection for eczema is warranted. Increased Ratings Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. 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 the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 6. Increased rating for the left eye. The Veteran’s left eye disability is rated under Diagnostic Code 6099-6009, effective from April 22, 2009. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. The provisions of 38 C.F.R. § 4.27 provide that unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and 99. Here, the hyphenated diagnostic code indicates that the Veteran’s left eye disability is rated as analogous to a disease of the eye (Diagnostic Code 6099) under the criteria for unhealed eye injury (Diagnostic Code 6009). 38 C.F.R. § 4.79. Under the regulations that went into effect on December 10, 2008, an eye injury is to be evaluated on the basis of either visual impairment due to the particular condition or incapacitating episodes, whichever results in a higher rating. 38 C.F.R. § 4.79, Diagnostic Codes 6000-6009. With respect to field of vision impairment, 38 C.F.R. § 4.76a, Table III, the normal visual field extent at the 8 principal meridians totals 500 degrees. The normal for the 8 principal meridians are as follows: 85 degrees temporally; 85 degrees down temporally; 65 degrees down; 50 degrees down nasally; 60 degrees nasally; 55 degrees up nasally; 45 degrees up; and 55 degrees up temporally. The extent of visual field contraction in each eye is determined by recording the extent of the remaining visual fields in each of the eight 45-degree principal meridians. The degrees lost are then added together to determine the total number of degrees lost, which are subtracted from 500. The total remaining degrees of the visual field are then divided by eight to represent the average contraction for rating purposes. 38 C.F.R. § 4.76a. Under Diagnostic Code 6080, visual field defects are evaluated as follows: A 10 percent evaluation for concentric contraction of visual field with remaining field of 46 to 60 degrees bilaterally or unilaterally; with remaining field of 31 to 45 degrees unilaterally; with remaining field of 16 to 30 degrees unilaterally; loss of superior half of visual field bilaterally or unilaterally; loss of interior half of visual field unilaterally; loss of nasal half of visual field bilaterally or unilaterally; and loss of temporal half of visual field unilaterally. A 20 percent evaluation if assigned for concentric contraction of visual field with remaining field of 6 to 15 degrees unilaterally. A 30 percent evaluation is assigned for concentric contraction of visual field with remaining field of 31 to 45 degrees bilaterally; remaining field of 5 degrees unilaterally; loss of inferior half of visual filed bilaterally; loss of temporal half of visual field bilaterally; and homonymous hemianopsia visual filed defects. A 50 percent rating is assigned for concentric contraction of visual field with remaining field of 16 to 30 degrees bilaterally. A 70 percent rating is assigned for concentric contraction of visual field with remaining field of 6 to 15 degrees bilaterally. A 100 percent rating is assigned for concentric contraction of visual field with remaining field of 5 degrees bilaterally. Visual impairment is also rated based on impairment of visual acuity (excluding developmental errors of refraction). 38 C.F.R. § 4.79, Diagnostic Codes 6061-6066. 38 C.F.R. § 4.76(b) dictates that evaluation of visual acuity should be done on the basis of corrected distance vision with central fixation, unless the lens required to correct distance vision in the poorer eye differs by more than three diopters from the lens required to correct distance vision in the better eye. A 10 percent rating is warranted only when there is (1) 20/50 vision in one eye with 20/40 or 20/50 vision in the other eye; (2) 20/70 vision in one eye with 20/40 vision in the other eye; or (3) 20/100 vision in one eye with 20/40 vision in the other eye. A 20 percent rating is warranted when there is (1) 20/70 vision in one eye with 20/50 vision in the other eye; (2) 20/100 vision in one eye with 20/50 vision in the other eye; (3) 20/200 vision in one eye with 20/40 vision in the other eye; or (4) 15/200 vision in one eye with 20/40 vision in the other eye. A 30 percent rating is warranted (1) when vision in both eyes is correctable to 20/70; (2) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/70; (3) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/50; (4) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/50; (5) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/40; (6) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/40; and (7) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/40. A 40 percent rating is warranted (1) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/70; (2) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/50; (3) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/50; (4) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/50 or (5) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/40. A 50 percent disability rating is warranted (1) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/100; (2) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/70; (3) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/70; (4) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/70; or (5) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/50. A 60 percent disability rating is warranted (1) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/100; (2) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/100; (3) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/200; (4) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/100; (5) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/100; or (6) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/70 or 20/100. A 70 percent disability rating is warranted (1) when vision in one eye is correctable to 20/200 and vision in the other eye is correctable to 20/200; (2) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 20/200; (3) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 20/200; (4) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 20/200; (5) when vision in one eye is no more than light perception and vision in the other eye is correctable to 20/200; or (6) when there is anatomical loss of one eye and vision in the other eye is correctable to 20/200. An 80 percent disability rating is warranted (1) when vision in one eye is correctable to 15/200 and vision in the other eye is correctable to 15/200; (2) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 15/200; (3) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 15/200; (4) when vision in one eye is no more than light perception and vision in the other eye is correctable to 15/200; or (5) when there is anatomical loss of one eye and vision in the other eye is correctable to 15/200. A 90 percent disability rating is warranted only (1) when vision in one eye is correctable to 10/200 and vision in the other eye is correctable to 10/200; (2) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 10/200; (3) when vision in one eye is no more than light perception and vision in the other eye is correctable to 10/200; or (4) when there is anatomical loss of one eye and vision in the other eye is correctable to 10/200. A 100 percent disability rating is warranted only (1) when vision in one eye is correctable to 5/200 and vision in the other eye is correctable to 5/200; (2) when vision in one eye is no more than light perception and vision in the other eye is correctable to 5/200; (3) when there is anatomical loss of one eye and vision in the other eye is correctable to 5/200; (4) when there is no more than light perception in both eyes; or (5) when there is anatomical loss of both eyes. To determine the rating for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service-connected, separately rate the visual acuity and visual field defect, expressed as a level of visual acuity, and combine them under the provisions of § 4.25. In addition, for the period of appeal prior to May 13, 2018, the General Rating Formula for Diagnostic Codes 6000 through 6009 provides for a 10 percent disability rating for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent disability rating is awarded for disability with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. With incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months, a 40 percent evaluation is in order. Finally, a maximum schedular rating of 60 percent is assigned for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. For VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. Effective May 13, 2018, VA promulgated a final rule that amends the General Rating Formula, providing a 10 percent disability rating for documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months. A 20 percent rating is warranted for documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months. A 40 percent rating is warranted for documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months. A 60 percent rating is warranted for documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months. For VA purposes, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Schedule for Rating Disabilities: The Organs of Special sense and Schedule of Ratings – Eye, 83 Fed. Reg. 15,316 (Apr. 10, 2018). To determine the rating for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service-connected, separately rate the visual acuity and visual field defect, expressed as a level of visual acuity, and combine them under the provisions of § 4.25. 38 C.F.R. § 4.77(c). The Board concludes that a compensable rating for the Veteran’s left eye disability is not warranted at any point during the period of appeal. In a May 2009 VA eye examination, the Veteran’s corrected left eye distance vision was 20/20-2 and near vision was 20/25, which the examiner attributed to the paracentral cornea scar. His pupil did now show an afferent pupillary defect (APD), extraocular muscles showed full range of motion, and confrontation field was full to finger counting. The Veteran denied having floaters, flashes, or diplopia (double vision). VA treatment records indicate that in September 2009, September 2010, July 2012, and August 2013 optometry appointments, the Veteran’s prescription was adjusted. He was consistently noted to have full range of motion of the extraocular muscles and full confrontation field to finger counting. He was prescribed artificial tear drops for both eyes and told to use warm compresses; however, in the July 2012 and August 2013 appointment, he declined a prescription for artificial tear drops. He was also noted to have a pigment clump at the second bifurcation of the sup branch venule, which did not show any changes. The Veteran had another VA eye examination in December 2015. He reported left eye pain occurring once or two times per week for the past three months, which was relieved with napping or Benadryl. Upon examination, corrected near and distance vision was 20/40 or better. His pupils were equal in diameter, round, and reactive to light. There was no anatomical loss, light perception only, extremely poor vision, blindness, a corneal irregularity that resulted in severe irregular astigmatism, or diplopia. There was no visual field defect, including contraction or loss of a visual field, or a scotoma. His diagnoses included left eye injury, bilateral cataracts, and dry eye syndrome, which had not caused any incapacitating episodes in the past 12 months. The examiner opined that the cataracts and dry eye syndrome were less likely than not related to the left eye injury, and that the cataracts were consistent with age-related changes. In a May 2016 VA optometry appointment, the Veteran requested new glasses to replace his old reading glasses. He noted that he had not used artificial tears in “several years.” He was noted to have full range of motion of the extraocular muscles and full confrontation field to finger counting. The Veteran was started on artificial tears again. In sum, the Board finds that an initial compensable rating for the service-connected left eye disability is not warranted. To warrant a compensable rating, the evidence would need to show impairment in visual field, impairment in visual acuity (20/50 or worse in the left eye), incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months (for the period of appeal prior ot May 13, 2018), or incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months (for the period of appeal from May 13, 2018). Here, however, the Veteran has not been found to have any impairment in visual acuity or visual field at any point during the period of appeal. Rather, his left eye corrected visual acuity has consistently been noted to be 20/40 or better, his visual field has never been noted to have a defect, and he has not complained of or been treated for an incapacitating episode. The Board has considered whether a higher rating or any additional ratings are warranted under an alternative diagnostic code, but as discussed above, finds that there is no indication that the Veteran had an impairment in visual acuity, impairment in visual field, or other symptoms or diagnoses to warrant any higher or additional ratings. As such, a compensable rating for the left eye disability is not warranted for any period of the appeal. 7. Increased rating for the left thumb. The Veteran’s left thumb laceration is rated under Diagnostic Code 7805, effective April 22, 2009. Under this diagnostic code, for scars other than of the head, face, or neck, scars are rated based on disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. In a May 2009 VA examination, the Veteran reported having progressive pain in the thumb at the interphalangeal (IP) and metacarpophalangeal (MP) joints. He indicated that the thumb hurt when he did any grabbing or lifting. On examination, the Veteran had a small hypopigmented area with a raised nodule that was mobile, which was consistent with the prior surgery. He had full range of motion of the IP and MP joints in flexion, extension, and adduction, without painful limitation. Sensation was intact and there was no laxity of the IP or MP joints. X-rays showed a normal left thumb without instability or degenerative changes. VA treatment records indicate that in a February 2015 psychiatry appointment, the Veteran reported having left thumb pain. In a December 2015 VA examination, the Veteran was noted to have a 2 centimeter (cm) linear scar on his left thumb. There was limited extension of the proximal phalanx of the thumb, which was the only pertinent finding, complication, condition, sign, or symptom associated with the scar. The scar was not painful, unstable, or due to burns. The examiner indicated the scar caused mild disability. The Veteran had a third VA examination of the left thumb in April 2016. He denied having flare-ups, functional loss, or functional impairment of the thumb. Ranges of motion were normal, including MCP and IP extension to zero degrees, MCP flexion to 100 degrees, and IP extension to 90 degrees. There was no gap between the pad of the thumb and the fingers. There was also no pain noted on examination, nor evidence of pain with use of the hand. After repetitive-use testing with at least three repetitions of movement, there was no additional functional loss or range of motion. The left hand did not have any ankylosis, and there were no other pertinent findings, complications, conditions, signs, or symptoms related to the left thumb scar. In sum, the Board finds that, for the entire period of appeal, the left thumb scar is linear, not deep, unstable, or resulting in any limitation of motion. The evidence is in equipoise on whether the left thumb scar results in mild disability. Affording the Veteran the benefit of the doubt, the Board finds that a 10 percent rating is warranted. A rating in excess of 10 percent under an alternative or additional diagnostic code is not warranted. Diagnostic Code 7800 contemplates scars of the head, face or neck and is not here for consideration. Diagnostic Code 7801 contemplates scars not of the head, face, or neck that are deep and nonlinear. Diagnostic Code 7802 contemplates scars due to other causes not of the head, face, or neck, that are superficial and nonlinear. Diagnostic Code 7804 contemplates scars that are unstable or painful. The Board acknowledges the Veteran reported having pain in the May 2009 VA examination and in a 2015 VA treatment record; however, in the May 2009 VA examination and two subsequent examinations in 2015 and 2016, the Veteran was not found to have pain in the left thumb. The Veteran is competent to report that he feels his scar is worse than evaluated and, by this decision, the Board is granting an evaluation of 10 percent, and no greater. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, neither the Veteran nor his representative are competent to make medical determinations as to the severity or nature of his left thumb scar. Thus his testimony alone, without corroborating medical evidence, is insufficient to outweigh that of the 2009, 2015, and 2016 VA medical examiners. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The medical evidence presents no other findings, signs or symptoms, complications or conditions that are the result of the left thumb scar. As such, an initial 10 percent rating for the left thumb laceration is warranted, and a rating in excess of 10 percent is not warranted for any period of the appeal. REASONS FOR REMAND 1. Service connection for an acquired psychiatric disorder is remanded. The Board remanded this issue in August 2015 to afford the Veteran a VA psychiatric examination to determine the nature and etiology of all psychiatric disorders. The examiner was directed to first indicate whether the Veteran met the diagnostic criteria for a PTSD diagnosis, and whether the Veteran had any other acquired psychiatric disorder diagnoses. The examiner was next instructed to indicate whether the Veteran had any acquired psychiatric disorders at any point during the period of appeal, even if currently resolved. For all diagnoses, the examiner was to opine on whether it was at least as likely as not that the diagnosis was related to service. The examiner was to specifically discuss past diagnoses of dysthymia, insomnia, and depressive disorder, and also to specifically discuss whether there is any medical reason to accept or reject the Veteran’s contentions that he has manifested symptoms of PTSD and/or an acquired psychiatric disorder since service discharge. Finally, the examiner was to consider a VA clinician’s comments that the Veteran’s symptoms of night sweats and insomnia since service may be manifestations of PTSD. The Veteran had a VA PTSD examination in December 2015. The examiner concluded that the Veteran did not meet the diagnostic criteria for a PTSD diagnosis, including taking into account the sleep disturbances. The Veteran was found to have a diagnosis of unspecified depressive disorder, which was due to stressors including a lack of work and concerns about not being able to contribute financially to the household, and was less likely than not related to his military service. The examiner did not, however, address whether the Veteran had any acquired psychiatric disorders at any point during the period of appeal, to include past diagnoses of PTSD, dysthymia, and insomnia. The Board therefore finds that there was not substantial compliance with the remand directives and remand is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that where the remand of the Board or the Court is not complied with, the Board errs as a matter of law when it fails to ensure compliance). 2. Increased ratings for the lumbar spine disability, chronic fatigue syndrome, and irritable bowel syndrome and an earlier effective date for the award of service connection for irritable bowel syndrome are remanded. The RO granted service connection for the lumbar spine disability, chronic fatigue syndrome, and irritable bowel syndrome in an April 2018 rating decision. The lumbar spine disability was assigned a 10 percent rating effective April 22, 2009; chronic fatigue syndrome was assigned a noncompensable rating effective April 22, 2009; and irritable bowel syndrome was assigned a noncompensable rating effective December 14, 2015. In May 2018, the Veteran submitted a timely notice of disagreement with the initial disability ratings and the effective date for service connection for irritable bowel syndrome. A Statement of the Case (SOC) has not been issued. As such, the Board is required to remand the issues for issuance of an SOC. Manlincon v. West, 12 Vet. App. 238 (1999). The matters are REMANDED for the following action: 1. Contact the VA examiner who conducted the December 2015 VA PTSD examination (or a suitable replacement), and ask the examiner to review the record and prepare an addendum medical opinion. After reviewing the entire claims folder, including VA treatment records noting diagnoses of PTSD, dysthymia, and insomnia, the examiner should indicate whether the Veteran had any acquired psychiatric disorders other than unspecified depressive disorder at any point during the period of appeal, even if such diagnoses are currently resolved. For any acquired psychiatric disorder that has existed during the pendency of appeal, the examiner should opine on whether it is at least as likely as not that such disorder(s) had its onset in service or is otherwise related to events(s) in service. In providing this opinion, the examiner should specifically discuss whether any past diagnoses were incorrect and/or currently resolved. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion(s), the AOJ should schedule the Veteran for such examination. A complete rationale for all opinions is required. 2. Issue an SOC to the Veteran and his representative addressing the issues of entitlement to increased initial ratings for the lumbar spine disability, chronic fatigue syndrome, and irritable bowel syndrome, and entitlement to an earlier effective date for the grant of service connection for irritable bowel syndrome. The Veteran and his representative should be advised of the time limit in which to file a Substantive Appeal. Then, if the appeal is timely perfected, the issues should be returned to the Board for further appellate consideration, if otherwise in order. 3. After completing all indicated development, and any additional development deemed necessary, readjudicate the claims in light of all the evidence of record. If any benefit sought on appeal remains denied, then a fully responsive Supplemental Statement of the Case should be furnished to the Veteran and his representative and they should be afforded a reasonable opportunity for response. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Nelson, Counsel