Citation Nr: 18144581 Decision Date: 10/24/18 Archive Date: 10/24/18 DOCKET NO. 16-00 696 DATE: October 24, 2018 ORDER New and material evidence has not been received; as such, the application to reopen a claim of entitlement to service connection for left elbow cellulitis is denied. New and material evidence has not been received; as such, the application to reopen a claim of entitlement to service connection for Hepatitis A is denied. New and material evidence having been received, the claim of service connection for Hepatitis C is reopened. Service connection for a liver transplant is granted. Service connection for sleep apnea is granted. Service connection for a heart disability is granted. Service connection for a prostate disability is denied. Entitlement to an effective date earlier than February 7, 2014, for the grant of service connection for posttraumatic stress disorder (PTSD) and alcohol abuse, in remission is denied. Entitlement to an effective date earlier than February 7, 2014, for the grant of service connection for tinnitus is denied. Entitlement to an effective date earlier than February 7, 2014, for the grant of service connection for bilateral hearing loss is denied. Entitlement to an initial compensable rating for bilateral hearing loss is denied. REMANDED Entitlement to service connection for Hepatitis C is remanded. Entitlement to an initial disability rating in excess of 70 percent for PTSD and alcohol abuse, in remission is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s claim for service connection for left elbow cellulitis was denied in an October 1974 administrative decision on the basis of failure to report for a scheduled VA examination. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 2. The evidence received since the October 1974 denial, by itself or when considered with previous evidence of record, does not relate to an unestablished fact necessary to substantiate the claim for service connection for left elbow cellulitis, and therefore does not raise a reasonable possibility of substantiating the claim for service connection for left elbow cellulitis. 3. The Veteran’s claim for service connection for hepatitis was denied in an October 1974 administrative decision on the basis of failure to report for a scheduled VA examination. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 4. The evidence received since the October 1974 denial, by itself or when considered with previous evidence of record, does not relate to an unestablished fact necessary to substantiate the claim for service connection for Hepatitis A, and therefore does not raise a reasonable possibility of substantiating the claim for service connection for Hepatitis A. 5. The Veteran’s claim for service connection for Hepatitis C was denied in a March 2005 rating decision on the basis that the evidence failed to establish a nexus to service. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 6. The Veteran’s request to reopen his claim for service connection for Hepatitis C was denied in an August 2007 administrative decision on the basis of a lack of new and material evidence. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 7. Evidence received since the August 2007 administrative decision raises a substantial possibility of substantiating the claim of service connection for Hepatitis C. 8. The probative evidence of record is at least in equipoise as to whether the Veteran’s liver transplant was etiologically related to his service-connected PTSD and alcohol abuse, in remission. 9. The probative evidence of record is at least in equipoise as to whether the Veteran’s sleep apnea is etiologically related to his service-connected PTSD and alcohol abuse, in remission. 10. The Veteran served in the Republic of Vietnam during the Vietnam Era and was therefore presumptively exposed to herbicide agents. 11. The Veteran has a current diagnosis of atherosclerotic cardiovascular disease. 12. The Veteran’s prostate disability initially manifested many years after separation from service and is not shown to be etiologically related to service. 13. The Veteran’s claim for service connection for PTSD was denied in a March 2005 rating decision. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year, and it became final. 14. VA received a claim for service connection for a mental health condition on February 7, 2014. The September 2014 rating decision resulting from that claim granted service connection for PTSD and alcohol abuse, in remission. There is no indication of an attempt to reopen the claim between March 2005 and February 7, 2014. 15. There is no indication of a claim for service connection for tinnitus prior to February 7, 2014. 16. The Veteran’s claim for service connection for a “bad eardrum” was denied in an October 1974 administrative decision. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year, and it became final. 17. The Veteran’s claim for service connection for bilateral hearing loss was denied in a March 2005 rating decision. He was notified of this decision, did not timely disagree with it or submit new and material evidence within one year, and it became final. 18. VA received a claim for service connection for tinnitus on February 7, 2014. The August 2015 rating decision resulting from that claim construed it to sympathetically include a claim for hearing loss and granted service connection for bilateral hearing loss and tinnitus. There is no indication of an attempt to reopen the claim between March 2005 and February 7, 2014. 19. During the period on appeal, the Veteran’s bilateral hearing loss was not manifested by worse than a Level I hearing loss in each ear. CONCLUSIONS OF LAW 1. The October 1974 administrative decision is final with regard to the issue of service connection for cellulitis. New and material evidence has not been received to reopen a claim for service connection for left elbow cellulitis. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2017). 2. The October 1974 administrative decision is final with regard to the issue of service connection for hepatitis. New and material evidence has not been received to reopen a claim for service connection for Hepatitis A. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 3. The August 2007 administrative decision is final with regard to the issue of service connection for Hepatitis C. New and material evidence sufficient to reopen the claim of service connection for Hepatitis C has been received. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 4. With resolution of reasonable doubt in the Veteran’s favor, the criteria for a grant of service connection for a liver transplant have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 5. With resolution of reasonable doubt in the Veteran’s favor, the criteria for a grant of service connection for sleep apnea have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 6. With resolution of reasonable doubt in the Veteran’s favor, the criteria for a grant of service connection for a heart disability have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 7. A prostate disability was not incurred in or aggravated by service and may not be presumed to have been incurred in or as a result of service. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 8. The criteria for entitlement to an effective date prior to February 7, 2014, for the grant of service connection for PTSD and alcohol abuse, in remission are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105 (2012); 38 C.F.R. §§ 3.104, 3.400, 20.302, 20.1103 (2017). 9. The criteria for entitlement to an effective date prior to February 7, 2014, for the grant of service connection for tinnitus are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105; 38 C.F.R. §§ 3.104, 3.400, 20.302, 20.1103. 10. The criteria for entitlement to an effective date prior to February 7, 2014, for the grant of service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105; 38 C.F.R. §§ 3.104, 3.400, 20.302, 20.1103. 11. During the period on appeal, the criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.385, 4.1-4.14, 4.85, 4.86, Diagnostic Code 6100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from December 1969 to February 1973, including service in the Vietnam War. This matter is on appeal from September 2014, December 2014, and August 2015 rating decisions. Neither the Veteran nor his attorney have raised any issue with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 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; 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). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Left Elbow Cellulitis – New and Material Evidence The Veteran contends that he has left elbow cellulitis that is etiologically related to his active duty service. In general, rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured to that claim. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence is neither cumulative nor redundant of evidence of record at the time of the last prior final denial and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). However, evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343, 1347 (Fed. Cir. 2000). In deciding whether new and material evidence has been submitted, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is generally “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Until the Veteran meets his threshold burden of submitting new and material evidence sufficient to reopen his claim of entitlement to service connection, the benefit of the doubt doctrine does not apply. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). The Veteran was denied service connection for cellulitis in an October 1974 administrative decision. He did not submit a Notice of Disagreement or submit new and material evidence within one year of the administrative decision. Therefore, the October 1974 administrative decision is final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.302, 20.1103. The basis for the October 1974 denial was a failure to report for a VA examination. (The Board notes that the Veteran returned this letter to indicate his willingness to report for examination in February 2015; however, that was limited to the issue of service connection for hearing loss.) The question is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in October 1974 that is neither redundant nor cumulative, and that raises a reasonable possibility of substantiating a claim that the Veteran currently has left elbow cellulitis as a result of active duty service. The evidence that was of record at the time of the October 1974 administrative decision included the Veteran’s service treatment records, which note treatment for left elbow cellulitis. Since the October 1974 administrative decision, the Veteran has not presented any non-cumulative evidence which indicates that he currently has left elbow cellulitis or that there is a nexus between any current left elbow cellulitis and any injury or illness in service. In May 2004, he stated that he had a left elbow infection in service. This is cumulative of the Veteran’s service treatment records, which note that he had a furuncle on his left elbow that required an incision and drainage procedure. Because the evidence received since the last final decision is cumulative of the evidence already of record and does not provide a reasonable possibility of substantiating the claim, the Veteran has not submitted and VA has not otherwise received new and material evidence and the claim of entitlement to service connection for left elbow cellulitis is not reopened. 2. Hepatitis A – New and Material Evidence The Veteran contends that he has Hepatitis A that is etiologically related to his active duty service. The Veteran was denied service connection for hepatitis in an October 1974 administrative decision. He did not submit a Notice of Disagreement or submit new and material evidence within one year of the administrative decision. Therefore, the October 1974 administrative decision is final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.302, 20.1103. The basis for the October 1974 denial was a failure to report for a VA examination. (The Board notes that the Veteran returned this letter to indicate his willingness to report for examination in February 2015; however, that was limited to the issue of service connection for hearing loss.) The question is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in October 1974 that is neither redundant nor cumulative, and that raises a reasonable possibility of substantiating a claim that the Veteran currently has Hepatitis A as a result of active duty service. The evidence that was of record at the time of the October 1974 administrative decision included the Veteran’s service treatment records, which note treatment for Hepatitis A. Since the October 1974 administrative decision, the Veteran has not presented any non-cumulative evidence which indicates that he currently has Hepatitis A or that there is a nexus between any current Hepatitis A and any injury or illness in service. The Veteran has submitted an October 1995 private treatment record which notes that January 1995 hepatitis serology was negative for antibodies to Hepatitis A; evidence of the absence of a disability is, by definition, not evidence that can substantiate a claim. Because the evidence received since the last final decision is cumulative of the evidence already of record and does not provide a reasonable possibility of substantiating the claim, the Veteran has not submitted and VA has not otherwise received new and material evidence and the claim of entitlement to service connection for Hepatitis A is not reopened. 3. Hepatitis C – New and Material Evidence The Veteran contends that he has Hepatitis C that is etiologically related to his active duty service. The Veteran was denied service connection for hepatitis in an October 1974 administrative decision. He did not submit a Notice of Disagreement or submit new and material evidence within one year of the administrative decision. Therefore, the October 1974 administrative decision is final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.302, 20.1103. The basis for the October 1974 denial was a failure to report for a VA examination. (The Board notes that the Veteran returned this letter to indicate his willingness to report for examination in February 2015; however, that was limited to the issue of service connection for hearing loss.) The Veteran was denied service connection for Hepatitis C in a March 2005 rating decision. He did not submit a Notice of Disagreement or submit new and material evidence within one year of the rating decision. Therefore, the March 2005 rating decision is final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.302, 20.1103. The basis for the March 2005 denial was a lack of evidence of nexus to service. The Veteran’s request to reopen his claim for service connection for Hepatitis C was denied in an August 2007 administrative decision. He did not submit a Notice of Disagreement or submit new and material evidence within one year of the administrative decision. Therefore, the August 2007 administrative decision is final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.302, 20.1103. The basis for the August 2007 denial was a lack of new and material evidence. The question is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in August 2007, that is neither redundant nor cumulative, and that raises a reasonable possibility of substantiating a claim that the Veteran currently has Hepatitis C as a result of active duty service. The evidence that was of record at the time of the August 2007 administrative decision included the Veteran’s service treatment records and private treatment records. Since the August 2007 administrative decision, the Veteran has submitted multiple private medical opinions on the issue of nexus to service. As the record now contains more evidence pertinent to the issue of nexus to service than it did in August 2007, the Board finds that new and material evidence has been received which pertains to previously unestablished facts necessary to support the claim. As this evidence raises a reasonable possibility of substantiating the claim, satisfying the criteria of 38 C.F.R. § 3.156(a) for new and material evidence, the claim is reopened. 4. Liver Transplant – Service Connection The Veteran has undergone a liver transplant, which he contends was etiologically related to his service-connected PTSD and alcohol abuse, in remission. The Veteran underwent a liver transplant in June 2007 at a private medical facility. The treatment provider’s diagnosis was “End-stage liver disease secondary to hepatitis C and alcohol.” The Veteran has also submitted an August 2017 medical opinion by a physician who discussed the relationship between alcohol use and liver disease and opined that it was as likely as not that alcohol abuse contributed to the development of and significantly aggravated his liver condition. The record contains no medical evidence to the contrary. In light of the totality of the circumstances, and after resolving all reasonable doubt in the Veteran’s favor, the evidence of record supports a finding that it is at least as likely as not that the Veteran’s liver transplant was caused, at least in part, by his service-connected PTSD and alcohol abuse, in remission. Accordingly, the Board finds that granting service connection for a liver transplant is the decision that is the most consistent with VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. §§ 3.303(a), 3.310. 5. Sleep Apnea – Service Connection The Veteran has a current diagnosis of sleep apnea, which he contends was etiologically related to his service-connected PTSD and alcohol abuse, in remission. The Veteran has submitted an August 2017 medical opinion by a physician who noted the Veteran’s June 2015 sleep apnea diagnosis and opined that it was as likely as not that the Veteran’s service-connected PTSD and alcohol abuse, in remission, aided in the development of and permanently aggravated his sleep apnea. The physician’s rationale was that a recent study found “an arousal-based mechanism initiated by posttraumatic stress that promotes the development” of sleep apnea. The physician also found that the Veteran was unable to use CPAP treatment due to his anxiety symptoms, aggravating his sleep apnea. The record contains no medical evidence to the contrary. In light of the totality of the circumstances, and after resolving all reasonable doubt in the Veteran’s favor, the evidence of record supports a finding that it is at least as likely as not that the Veteran’s sleep apnea was caused, at least in part, by his service-connected PTSD and alcohol abuse, in remission. Accordingly, the Board finds that granting service connection for sleep apnea is the decision that is the most consistent with VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. §§ 3.303(a), 3.310. 6. Heart Disability – Service Connection By filing a claim for service connection, the Veteran has contended that his heart disability is related to his active duty service, but he has not raised any specific theory of nexus. Because the Veteran’s service records indicate service in the Republic of Vietnam from July 1970 to August 1971 and from October 1971 to December 1971, he is presumed to have been exposed to herbicides. 38 C.F.R. § 3.307. To give the Veteran the benefit of the doubt, the Board will assume that he is contending that his heart disability is due to exposure to herbicides during his active duty service. Certain diseases are deemed associated with herbicide exposure under current law. The list of those diseases includes ischemic heart disease, including but not limited to “atherosclerotic cardiovascular disease including coronary artery disease.” 38 C.F.R. § 3.309(e). Coronary artery disease is defined as “atherosclerosis of the coronary arteries.” Dorland’s Illustrated Medical Dictionary, 531 (32nd Ed. 2012). A July 2016 private x-ray report notes “coronary artery calcification, indicating atherosclerosis.” The Board therefore finds that it is at least as likely as not that the Veteran has coronary artery disease, which is presumptively service-connected. Accordingly, service connection for a heart disability is granted on this basis. 7. Prostate Disability – Service Connection The Veteran has a February 2009 diagnosis of benign prostatic hyperplasia (BPH) and a March 2015 diagnosis of prostatism. By filing a claim for service connection, he has contended that his prostate disability is related to his active duty service, but he has not raised any specific theory of nexus. To give the Veteran the benefit of the doubt, the Board will assume that he is also contending that his prostate disability is due to exposure to herbicides during his active duty service. The record does not reflect, and the Veteran does not contend, that a prostate disability had its onset in service. The Veteran’s service treatment records do not reflect any symptoms or complaint of, or diagnosis of a prostate disability. As stated above, the earliest mention of a prostate disability was more than 30 years after the Veteran’s separation from active duty service. The Veteran is competent to report on matters observed or within his personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, however, the Veteran is not competent to provide an etiology opinion for his prostate disability. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person to provide an opinion as to etiology. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran in this case is not shown to possess any pertinent medical training or expertise that would make him competent to render an opinion on the etiology of a prostate disability. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Thus, to the extent that the act of filing a claim for service connection expressed an opinion that the Veteran’s prostate disability is etiologically related to active duty service including as due to herbicide exposure, it is not a competent medical opinion and it cannot be assigned any probative weight. Certain diseases are deemed associated with herbicide exposure under current law. The list of those diseases includes prostate cancer, but does not include BPH or prostatism. 38 C.F.R. § 3.309(e). However, a claimant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, the fact that a veteran does not meet the requirements for service connection on a presumptive basis does not in and of itself preclude the establishment of service connection, as entitlement may alternatively be established on a direct basis. However, the record contains no evidence, other than the Veteran’s implied assertion, that his prostate disability was caused or exacerbated by his active duty service, including as a result of exposure to herbicides. As stated above, that assertion cannot be assigned any probative weight. Moreover, the record contains no competent evidence that it is possible for exposure to herbicides to cause or aggravate BPH or prostatism. Because the preponderance of the evidence is thus against finding that the Veteran’s prostate disability is etiologically related to his active duty service, entitlement to service connection for a prostate disability is denied. Effective Date Unless specifically provided otherwise by statute, the effective date of an award for compensation benefits based on (1) an original claim, (2) a claim reopened after final adjudication, or (3) a claim for increase, is the date VA received the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400; Lalonde v. West, 12 Vet. App. 377, 382 (1999). With regard to a claim for increase, the effective date can be up to one year earlier than the date of the claim if it is factually ascertainable, based on all evidence of record, that an increase in disability occurred within one year of the date of claim. 38 C.F.R. § 3.400. 8. PTSD and Alcohol Abuse, in Remission – Effective Date The Veteran contends that he should be granted an effective date earlier than February 7, 2014, for service connection for PTSD and alcohol abuse, in remission. The Veteran first submitted a claim for entitlement to service connection for PTSD in May 2004. VA denied that claim in March 2005 and the Veteran did not submit a notice of disagreement or additional evidence within the one year period following the decision. The decision became final and not subject to revision on the same factual basis. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. The Board has reviewed the claims file for any document, submitted after the March 2005 rating decision but before the Veteran’s February 7, 2014, claim, that could be considered a claim for service connection. Lalonde, 12 Vet. App. at 381. Prior to March 24, 2015, a “claim” was defined as “a formal or informal communication in writing requesting a determination of entitlement[,] or evidencing a belief in entitlement, to a benefit.” 38 C.F.R. § 3.1(p) (2015). Any communication or action that (1) indicates an “intent to apply for one or more [VA] benefits” and (2) “identif[ies] the benefit sought” may be considered an informal claim. 38 C.F.R. § 3.155(a) (2015). The Board has found no communication from the Veteran to VA that could be construed as a request to reopen the claim of entitlement to service connection for PTSD prior to the claim submitted on February 7, 2014. Moreover, neither the Veteran nor his attorney assert that the Veteran filed an informal or formal claim during that time. In order for the Veteran to be awarded an effective date based on the claim that was denied in the March 2005 rating decision, he has to show clear and unmistakable error (CUE) in the prior denial as a collateral attack. Flash v. Brown, 8 Vet. App. 332, 340 (1995). Neither the Veteran nor his attorney have raised CUE to overcome the finality of the March 2005 rating decision denying service connection. Any claim of CUE must be pled with specificity. See Andre v. Principi, 301 F.3d 1354 (Fed. Cir. 2002). This specific allegation must assert more than merely disagreement with how the facts of the case were weighed or evaluated. Persuasive reasons must be given as to why the result would have been manifestly different but for the alleged error. For those reasons, the Board concludes that the Veteran is not entitled to an effective date earlier than February 7, 2014, for service connection for PTSD and alcohol abuse, in remission, which is the date of the claim that led to the grant of service connection. 9. Tinnitus – Effective Date The Veteran contends that he should be granted an effective date earlier than February 7, 2014, for service connection for tinnitus. The Veteran first submitted a claim for entitlement to service connection for tinnitus on February 7, 2014. The Board has reviewed the claims file for any document, submitted before the Veteran’s February 7, 2014, claim, that could be considered a claim for service connection. The Board has found no communication from the Veteran to VA that could be construed as a claim of entitlement to service connection for tinnitus prior to the claim submitted on February 7, 2014. Moreover, neither the Veteran nor his attorney assert that the Veteran filed an informal or formal claim during that time. For those reasons, the Board concludes that the Veteran is not entitled to an effective date earlier than February 7, 2014, for service connection for tinnitus, which is the date of the claim that led to the grant of service connection. 10. Bilateral Hearing Loss – Effective Date The Veteran contends that he should be granted an effective date earlier than February 7, 2014, for service connection for bilateral hearing loss. The Veteran first submitted a claim for entitlement to service connection for a “bad eardrum” in March 1973. VA denied that claim in October 1974 and the Veteran did not submit a notice of disagreement or additional evidence within the one year period following the decision. The decision became final and not subject to revision on the same factual basis. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. The Veteran then submitted a claim for entitlement to service connection for hearing loss in March 2004. VA denied that claim in March 2005 and the Veteran did not submit a notice of disagreement or additional evidence within the one year period following the decision. The decision became final and not subject to revision on the same factual basis. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. The Board has reviewed the claims file for any document, submitted after the March 2005 rating decision but before the Veteran’s February 7, 2014, claim, that could be considered a claim for service connection. Lalonde, 12 Vet. App. at 381. The Board has found no communication from the Veteran to VA that could be construed as a request to reopen the claim of entitlement to service connection for hearing loss prior to the claim submitted on February 7, 2014. Moreover, neither the Veteran nor his attorney assert that the Veteran filed an informal or formal claim during that time. In order for the Veteran to be awarded an effective date based on the claim that was denied in the March 2005 rating decision, he has to show clear and unmistakable error (CUE) in the prior denial as a collateral attack. Flash, 8 Vet. App. at 340. Neither the Veteran nor his attorney have raised CUE to overcome the finality of the March 2005 rating decision denying service connection. Any claim of CUE must be pled with specificity. See Andre, 301 F.3d 1354. This specific allegation must assert more than merely disagreement with how the facts of the case were weighed or evaluated. Persuasive reasons must be given as to why the result would have been manifestly different but for the alleged error. The Board notes that, in a February 2015 statement, the Veteran asserted that he did not receive the October 1974 administrative decision and expressed disagreement with its “denial on hearing disability.” It is unnecessary for the Board to decide whether the 1973 claim for service connection for a “bad eardrum” was a claim for service connection for hearing loss or to evaluate any challenge to the finality of the October 1974 administrative decision with regard to this issue because the finality of the subsequent rating decision in March 2005 renders any challenge to the finality of the prior decision moot. For those reasons, the Board concludes that the Veteran is not entitled to an effective date earlier than February 7, 2014, for service connection for bilateral hearing loss, which is the date of the claim that led to the grant of service connection. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4 (2017). 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. “Staged” ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Given the nature of the present claim for a higher initial evaluation, the Board has considered all evidence of severity since the effective date for the award of service connection. Fenderson v. West, 12 Vet. App. 119 (1999). 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. 11. Bilateral Hearing Loss – Increased Rating The Veteran contends that his service-connected bilateral hearing loss warrants a compensable rating. It is currently service-connected with a noncompensable rating on and after February 7, 2014. 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 pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. §§ 3.385, 4.85, Diagnostic Code 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, 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. 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). An exceptional pattern of hearing impairment occurs when the pure tone 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 pure tone 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). In July 2015, the Veteran was afforded a VA examination. The examiner diagnosed bilateral sensorineural hearing loss. The hearing examination results were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 30 55 75 LEFT 15 15 35 55 80 The puretone average in the right ear was 45 and the puretone average in the left ear was 46.25. Speech recognition was 98 percent in the right ear and 94 percent in the left ear. The examiner noted the Veteran’s report of functional impact in the form of difficulty hearing speech and high-pitched noises. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The findings from the July 2015 VA examination require the use of Table VI for each ear. Applying the findings to that table yields findings of Level I hearing loss in each ear. 38 C.F.R. § 4.85, Diagnostic Code 6100. Where hearing loss is at Level I in each ear, a noncompensable rating is assigned under Table VII. Id. Other than his statements during the July 2015 VA examination cited above, the Veteran has not offered any lay statements as to the severity of his hearing loss during the period on appeal. To the extent that those statements and the fact that he appealed the assigned rating constitute assertions that his hearing loss is worse than its currently assigned noncompensable rating, he is competent to report a decrease in hearing acuity and his statements during the examination are credible. The Board acknowledges the Veteran’s complaints regarding the impact of hearing loss on his daily life, but his lay assertions do not constitute competent evidence to indicate that his hearing disability is worse than has been recorded in his VA examination or that hearing loss has functionally affected the Veteran in any more severe ways than have been discussed in the record and were already considered by medical professionals. The competence of a lay person to provide a medical opinion must be determined on a case by case basis. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran in this case is not competent to make such a conclusion. Determining the severity of hearing loss involves using specialized equipment and interpreting audiological test results. The record does not show that the Veteran possesses the training or experience needed to accomplish these actions. The probative value of his assertions is low. The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes, difficulty hearing speech and high-pitched noises, is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran’s main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Martinak, 21 Vet. App. 447. In brief, the medical examination findings are of greater probative value than the Veteran’s allegations regarding the severity of his hearing loss and the nature of any functional impairment is adequately reflected by those medical findings. Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a compensable rating for hearing loss. In reaching the conclusions above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claims except to the extent granted above, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Service connection for Hepatitis C is remanded. VA must provide an examination with regard to a claim for disability compensation when there is competent evidence of a disability that may be associated with an in-service disease, injury or event, but there is insufficient information to make a decision on the claim. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran has been diagnosed with Hepatitis C. The Veteran has proposed multiple causes, including vaccinations during Basic Training, an in-service left elbow wound, the Hepatitis A diagnosed during his active duty service, and sexual contact with prostitutes during his active duty service. The Veteran has submitted literature regarding the risk of contamination from his in-service vaccinations. The Veteran has also submitted two medical opinions by private physicians. The first, from August 2017, opined that co-infection of Hepatitis A and C is very common and that it was as likely as not that he contracted Hepatitis C during his active duty service. Citing a possible correlation between Hepatitis A and Hepatitis C is not, by itself, a sufficient rationale to warrant a finding of service connection. The second, from July 2018, opined that the Veteran might have had Hepatitis C instead of Hepatitis A during his active duty service and that, although a cause could not be determined with accuracy, it was “biologically plausible” that a contaminated vaccination was the cause. This does not rise to the level of an opinion that a nexus to service is at least as likely as not. However, the threshold for determining whether the evidence “indicates” that there “may” be a nexus between a current disability and an in-service event, injury, or disease is a low one. Id., at 83. This evidence meets that threshold, and an examination is necessary. 2. Entitlement to an initial disability rating in excess of 70 percent for PTSD and alcohol abuse, in remission is remanded. The Veteran was last afforded a VA examination for his service-connected PTSD and alcohol abuse, in remission in August 2014, more than four years ago. That examiner found that the Veteran did not appear to pose any threat of danger or injury to himself or others. VA treatment records from June 2015 and July 2015 note the Veteran’s report of increasing difficulty with anger, including nearly becoming physically violent toward his former spouse. During an April 2018 VA treatment appointment, the Veteran reported suicidal ideation. The Veteran has also submitted an August 2017 examination by a private psychologist; the report listed a significant number of additional symptoms. The record thus raises the possibility that the Veteran’s service-connected PTSD and alcohol abuse, in remission could now be more severe than the August 2014 examination report reflects. “Where the record does not adequately reveal the current state of the claimant’s disability, a VA examination must be conducted.” Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). 3. Entitlement to a TDIU is remanded. In a July 2018 statement, the Veteran’s attorney contends that the Veteran is unemployable as a result of his service-connected disabilities, including PTSD and alcohol abuse, in remission. The Board finds that the issue of entitlement to a TDIU has been raised by this statements in connection with the claim on appeal for an increased rating for the Veteran’s PTSD and alcohol abuse, in remission. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, the Agency of Original Jurisdiction (AOJ) should develop a claim for a TDIU in accordance with Rice. The matters are REMANDED for the following action: 1. Provide the Veteran and his attorney with notice concerning how to substantiate the claim for a TDIU, to include VA Form 21-8940. 2. Schedule the Veteran for an examination with an appropriate clinician for Hepatitis C. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide opinions as to the following: a. Determine whether it is at least as likely as not (50 percent or greater probability) that the Veteran has Hepatitis C that began during active service or is related to an incident of service. b. Determine whether it is at least as likely as not that the Veteran has Hepatitis C that is proximately due to or the result of his service-connected disabilities, including PTSD and alcohol abuse, in remission. c. Determine whether it is at least as likely as not that the Veteran has Hepatitis C that was aggravated (chronically worsened beyond its natural progression) by his service-connected disabilities, including PTSD and alcohol abuse, in remission. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: a. The November 1969 entrance examination, noting a tattoo. b. The January 1973 service treatment records diagnosing Hepatitis A. c. The October 1995 private treatment record noting positive antibodies to Hepatitis C and negative antibodies to Hepatitis A. d. The December 1995 private biopsy diagnosing chronic Hepatitis C. e. The April 2004 Risk Factors for Hepatitis Questionnaire completed by the Veteran. f. The Veteran’s May 2004, September 2014, and March 2016 statements regarding possible causes for his Hepatitis C. g. The literature submitted by the Veteran in support of a nexus between Hepatitis C and contaminated vaccinations. h. The August 2017 and July 2018 private medical opinions. The rationale for any opinion expressed should be provided. If an opinion cannot be made without resort to speculation, the examiner should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 3. Arrange for the Veteran to have an examination by an appropriate clinician for the purpose of determining the current severity of his PTSD and alcohol abuse, in remission. The electronic claims file must be made available to the examiner for review, and the examination must reflect that such review has been accomplished. The examiner is to provide a detailed review of the Veteran’s pertinent medical history, current complaints, and the nature and extent of any symptoms of PTSD and alcohol abuse, in remission. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: a. The June 2015 and July 2015 VA treatment records in which the Veteran reported difficulty with anger, including nearly becoming physically violent toward his former spouse. b. The August 2017 private examination report. c. The April 2018 VA treatment record in which the Veteran reported suicidal ideation. The rationale for any opinion expressed should be provided. If an opinion cannot be made without resort to speculation, the examiner should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 4. Readjudicate the claims. If the decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Ryan Frank, Counsel