Citation Nr: 18145390 Decision Date: 10/30/18 Archive Date: 10/26/18 DOCKET NO. 16-07 470 DATE: October 30, 2018 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for benign prostatic hypertrophy is denied. Entitlement to service connection for a skin disability is denied. Entitlement to an evaluation higher than 10 percent for lumbosacral strain is denied. Entitlement to an evaluation of 30 percent for migraine headaches for the period prior to May 14, 2015 is granted. Entitlement to an evaluation higher than 50 percent for migraine headaches for the period beginning May 14, 2015 is denied. Entitlement to an evaluation higher than 70 percent for mood disorder not otherwise specified (NOS) is denied. Entitlement to an effective date prior to March 18, 2013 for the grant of service connection for mood disorder NOS is denied. Entitlement to an effective date prior to August 7, 2012 for the grant of service connection for tinnitus is denied. Entitlement to a total rating based on unemployability due to service-connected disability (TDIU) is granted. REMANDED The issue of entitlement to service connection for a respiratory disability is remanded. The issue of entitlement to separate evaluations for radiculopathy of the bilateral lower extremities associated with lumbar strain is remanded. The issue of entitlement to an evaluation higher than 10 percent for supraventricular tachycardia is remanded. FINDINGS OF FACT 1. The Veteran does not have left ear hearing loss disability for VA compensation purposes. 2. Right ear hearing loss did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury, event, or disease. 3. Benign prostatic hypertrophy did not begin during active service, and is not otherwise related to an in-service injury, event, or disease. 4. A skin disability did not begin during active service, and is not otherwise related to an in-service injury, event, or disease. 5. Lumbosacral strain is manifested by forward flexion of the lumbosacral spine to 90 degrees or greater, with no objective evidence of painful motion; there is no evidence of incapacitating episodes of intervertebral disc syndrome (IVDS). 6. For the period prior to May 14, 2015, migraines were manifested by characteristic prostrating attacks averaging more frequently than once per month; there was no evidence that headaches were productive of severe economic inadaptability. 7. For the period from May 14, 2015, migraines are manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 8. Mood disorder NOS is productive of anxiety, problems with anger control, depression, sleep disturbance, and impairment of insight and judgment, resulting in occupational and social impairment with deficiencies in most areas. 9. The Veteran’s claim of entitlement to service connection for a psychiatric disorder was received on March 18, 2013. 10. The Veteran’s claim of entitlement to service connection for tinnitus was received on August 7, 2012. 11. The Veteran’s service connected disabilities render him unable to obtain and maintain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a) (2017). 2. The criteria for service connection for benign prostatic hypertrophy have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 3. The criteria for service connection for a skin disability have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 4. The criteria for an evaluation higher than 10 percent for lumbar strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5237, 5242, 5243 (2017). 5. For the period prior to May 14, 2015, the criteria for an evaluation of 30 percent for migraine headaches have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.20, 4.120, 4.124a, Diagnostic Code 8100 (2017). 6. For the period from May 14, 2015, the criteria for an evaluation higher than 50 percent for migraine headaches have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.20, 4.120, 4.124a, Diagnostic Code 8100 (2017). 7. The criteria for an evaluation higher than 70 percent for mood disorder not otherwise specified (NOS) have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130 Diagnostic Code 9440 (2017). 8. The criteria for an effective date prior to March 18, 2013 for the grant of service connection for mood disorder NOS have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2017). 9. The criteria for an effective date prior to August 7, 2012 for the grant of service connection for tinnitus have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2017). 10. The criteria for TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.340, 3.341, 4.1, 4.15, 4.16, 4.18, 4.19, 4.25 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service incurrence or aggravation of diseases of the central nervous system (e.g. hearing loss) may be presumed to have been incurred or aggravated if the disability is manifested to a compensable degree within one year of the Veteran’s discharge from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, “[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service.” Watson v. Brown, 4 Vet. App. 309, 314 (1993). 1. Entitlement to service connection for bilateral hearing loss The threshold for normal hearing is from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). For the purposes of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 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. Service records reflect that the Veteran served as a dental technician. Service treatment records are negative for any diagnosis, complaint, or abnormal finding indicating hearing loss. On annual physical examination in September 1982, audiometric testing revealed the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 0 5 0 LEFT 10 5 0 5 0 In March 1987, audiometric testing elicited the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 0 0 0 LEFT 10 5 0 5 0 On periodic examination in January 1988, audiometric testing elicited the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 0 0 LEFT 5 0 0 5 0 The examiner concluded that the Veteran was qualified for retention. On examination in September 1989, audiometric testing elicited the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 5 0 LEFT 5 0 0 0 0 On retirement examination in August 1990, audiometric testing revealed the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 0 0 LEFT 5 0 0 0 0 With respect to his medical history, the Veteran indicated that he did not know whether he had ear trouble or hearing loss. The examiner deemed the Veteran qualified for retirement, and made no notation of hearing loss. On VA examination in October 2012, the Veteran’s history was reviewed. The examiner noted that the Veteran’s occupational specialty was dental, and that he reported military noise exposure consisting of small arms fire, helicopter noise, and some explosions. He also noted the Veteran’s exposure to recreational noise exposure while target shooting with hearing protection, hunting without hearing protection, and race tracks with hearing protection. Audiometric testing revealed the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 20 45 LEFT 10 5 5 15 35 Speech recognition scores were 94 percent bilaterally. The examiner diagnosed sensorineural hearing loss. She concluded that it was not related to service. He reasoned that there was no hearing loss at separation. She noted that there was no evidence of a threshold shift during service, and that available audiograms reflected normal hearing bilaterally. Having carefully reviewed the evidence pertaining to this claim, the Board has determined that service connection is not warranted. Regarding the left ear, the record does not demonstrate hearing loss that is a disability for VA compensation purposes. In this regard, the Board observes that the evidence does not reflect puretone thresholds at 40 or greater in any relevant frequency, or 26 or greater in three or more relevant frequencies, or speech recognition scores less than 94 percent. As noted, VA regulations require that hearing loss be reported at a certain level before it will be considered a disability for compensation purposes. In this case, the record does not demonstrate that the Veteran has left ear hearing loss disability as defined by VA regulations. In the absence of proof of a present disability as defined by VA regulations, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). Accordingly, the claim of entitlement to service connection for left ear hearing loss disability must be denied. Although the Veteran’s current right ear hearing loss is at the level that is considered a disability for VA compensation purposes, the weight of the evidence does not demonstrate credible evidence of pathology in proximity to service or within years of separation. In this regard, the first post-service evidence showing complaints regarding hearing loss dates to the Veteran’s 2012 claim for service connection. Thus, service connection is not warranted on a presumptive basis. Moreover, while the evidence reveals that the Veteran has current right ear hearing loss disability, the most competent and probative evidence of record does not etiologically link this disability to service or any incident therein. Rather, the October 2012 VA examiner opined that hearing loss was not related to service. She concluded that, based on normal hearing sensitivity during service and at separation, it was less likely than not that hearing loss was related to or caused by military noise exposure. This examiner provided a reasoned opinion based on a complete review of the Veteran’s history, interview and examination, to include the type of noise exposure that the Veteran had during service. In assigning high probative value to the VA examiner’s opinion, the Board notes that she had the claims file for review, specifically discussed evidence contained in the claims file, obtained a history from the Veteran, and conducted a complete examination. There is no indication that the VA examiner was not fully aware of the Veteran’s history or that she misstated any relevant fact. The Board thus finds the VA examiner’s opinion to be of greater probative value than the Veteran’s unsupported statements. The Board acknowledges that the VA examiner relied, in part, on a lack of hearing loss diagnosis during service. 38 C.F.R. § 3.385 does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service, if there is sufficient evidence to demonstrate a relationship between the Veteran’s service and his current disability. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). That case does not state, however, that the lack of a diagnosis cannot be considered as a factor in determining whether a nexus exists. Here, the examiner fully reviewed the record, and specifically noted the Veteran’s service and post-service history. The Veteran’s lay statements were considered. However, on review of the entire record, in the examiner’s opinion, a relationship was not established. Because the examiner considered more than just the lack of a diagnosis, the Board finds that the opinion is, in fact, adequate for the purpose of deciding this claim. To the extent that the Veteran asserts that his current hearing loss is related to service, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and his assertions in that regard are entitled to some probative weight. He is competent to report incidents and symptoms in service and symptoms since then. He is not, however, competent to render an opinion as to the cause or etiology of the currently diagnosed hearing loss, because he does not have the requisite medical knowledge or training, and because such matter is beyond the ability of a lay person to observe. As discussed, the VA examiner considered the Veteran’s documented history, but ultimately concluded that the current hearing loss is not related to service. The Board finds the most probative evidence of record to be this opinion by the competent VA health care provider. The opinion was provided by a medical professional who reviewed the history, interviewed the Veteran, and provided opinions supported by rationale. The grant of service connection requires competent evidence to establish a diagnosis and, as in this case, relate the diagnosis to the Veteran’s service. While the record contains evidence of left ear hearing loss disability, the preponderance of the evidence is against finding that any such diagnosis is related to any injury or disease in service. Accordingly, the doctrine of reasonable doubt is not applicable in the instant appeal. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990); 38 C.F.R. § 3.102 (2017). 2. Entitlement to service connection for benign prostatic hypertrophy Service treatment records reflect that on annual physical examination in September 1982, the Veteran’s genitourinary system was clinically normal. Right epididymitis was assessed in January 1986. On periodic examination in January 1988, the Veteran’s genitourinary system was normal. Possible epididymitis was assessed in February 1989. An October 1989 record indicates that the Veteran’s prostate was tender; the assessment included rule out early prostatitis. On retirement examination in August 1990, the Veteran endorsed frequent or painful urination. The examiner noted frequent urination. He indicated that the Veteran’s genitourinary system was clinically normal. On VA examination in April 1991, the Veteran’s genitourinary system was noted to be “OK”. He had no relevant complaints. VA treatment records indicate a diagnosis of benign prostate hypertrophy. On VA examination in September 2012, the diagnosis was prostatic hypertrophy. The Veteran reported that he had experienced urinary frequency for several years. The examiner concluded that the claimed condition was less likely than not incurred in or caused by service. He noted that the Veteran was assessed with possible acute prostatitis in service, with no reoccurrence recorded. He stated that acute prostatitis was not a known cause of benign prostatic hypertrophy (BPH). He pointed out that BPH was very common in the Veteran’s age group. The Board concludes that, while the Veteran has a current diagnosis of BPH, and service treatment records show an instance of possible prostatitis, the preponderance of the evidence weighs against finding that the Veteran’s current BPH began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The record demonstrates that BPH was not diagnosed until many years following service, and that it is unrelated to service. To the extent that the Veteran asserts that he has BPH that is related to service, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. He is competent to report incidents and symptoms in service and symptoms since then. He is not, however, competent to render an opinion as to the cause or etiology of the current diagnosis because he does not have the requisite medical knowledge or training, and because this matter is beyond the ability of a lay person to observe. As discussed, the VA examiner considered the Veteran’s documented history, but ultimately concluded that the current BPH is not related to service. The Board finds the most probative evidence of record to be this opinion by the competent VA health care provider. The opinion was provided by a medical professional who reviewed the history, interviewed the Veteran, and provided opinions supported by rationale. The grant of service connection requires competent evidence to establish a diagnosis and, as in this case, relate the diagnosis to the Veteran’s service. While the record demonstrates a diagnosis of BPH, it does not contain reliable evidence which relates this claimed disability to any incident of service. For these reasons, the Board concludes that the claim of entitlement to service connection for BPH must be denied, as the preponderance of the evidence is against the claim. The doctrine of reasonable doubt is not applicable in the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for a skin disability In his 2012 claim, the Veteran requested service connection for a skin condition. He did not specify a diagnosis or indicate the nature of the skin condition for which he sought benefits. He indicated that he received treatment through VA. Service treatment records indicate that on annual physical examination in September 1982, the Veteran denied skin diseases. His skin was clinically normal. On periodic examination in January 1988, the Veteran’s skin was normal. In April 1990, the Veteran presented with oral sores and a lesion on his penis; the provider questioned whether there was a reaction to Dilantin, or severe hives. On retirement examination in August 1990, the Veteran endorsed skin diseases. The examiner noted mouth and penile ulceration of questionable etiology, possibly secondary to Dilantin. He did not indicate the state of the Veteran’s skin on clinical examination. He determined that the Veteran was qualified for retirement. On VA examination in April 1991, the only skin abnormality noted was a cluster of plantar warts on the Veteran’s right heel. However, VA treatment records obtained in support of the Veteran’s 2012 claim are negative for any diagnosis, complaint, or abnormal finding referable to his skin during the appeal period. Having reviewed the record, the Board concludes that the Veteran does not have a current skin disability. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). The Board acknowledges the Veteran’s contention that he has a skin condition; however, there is no competent evidence diagnosing such a disability, and the Veteran has not specified the nature of the skin condition for which he seeks service connection. The principle requiring a current disability has been repeatedly reaffirmed by the Federal Circuit, which has stated that “a veteran seeking disability benefits must establish... the existence of a disability [and] a connection between the veteran’s service and the disability.” Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). To the extent that the Veteran asserts that he has a skin condition that is related to service, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. He is competent to report incidents and symptoms; he is not; however, competent to render an opinion as to whether there is a currently existing skin disability, because he does not have the requisite medical knowledge or training, and because such matters are beyond the ability of a lay person to observe. For these reasons, the Board concludes that the claim of entitlement to service connection for a skin disability must be denied, as the preponderance of the evidence is against the claim. The doctrine of reasonable doubt is not applicable in the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings based on average impairment in earning capacity. 38 U.S.C. § 1155 (2012). Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. If there is a question as to which evaluation to apply to the Veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). 4. Entitlement to an evaluation higher than 10 percent for lumbar strain The Veteran seeks an evaluation higher than 10 percent for his lumbosacral spine disability. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Under the General Rating Formula for Diseases and Injuries of the Spine, the following evaluations are to be assigned for spinal disabilities with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. A 10 percent evaluation is warranted where there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. A 20 percent evaluation is warranted where there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted where there is forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula. Additionally, any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under the appropriate diagnostic codes. Id. at Note (1). Normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees and left and right lateral rotation are 0 to 30 degrees. The normal combined range of motion for the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, DCs 5235-5243 (2017). Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (memorandum decision); Nix v. Brown, 4 Vet. App. 462, 465 (1993); and Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Ankylosis has also been defined as stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Under the IVDS formula, a rating of 60 percent is warranted for incapacitating episodes with a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, IVDS Formula. For these purposes, an incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). A January 2012 VA X-ray report indicated mild thoracic spine degenerative changes. On VA examination in September 2012, the diagnosis was lumbar strain. The Veteran’s history was reviewed, and he reported daily pain. He did not report flare-ups. Range of motion testing revealed forward flexion to 90 degrees or greater, extension to 30 degrees or greater, rotation to 30 degrees or greater bilaterally, all with no objective evidence of painful motion. Lateral flexion was to 30 degrees or greater, with objective evidence of painful motion at 30 degrees or greater. Following repetitive motion testing, ranges of motion remained unchanged. The examiner noted that functional loss or impairment was due to pain. There was no evidence of pain to palpation or localized tenderness. There was no indication of guarding or muscle spasm. Muscle strength testing was 5/5 throughout. Reflexes and sensory were normal. Straight leg raising test was negative. He indicated that there was no evidence of IVDS. The current 10 percent evaluation contemplates forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. A higher, 20 percent evaluation requires evidence demonstrating forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Such is not shown by the objective evidence of record. Rather, VA examination indicates that the Veteran has forward flexion of 90 degrees or greater, and combined range of motion greater than 120 degrees. Moreover, there is no objective evidence of guarding, tenderness, or muscle spasm, and no indication of IVDS. Thus, the criteria for a higher evaluation are not met. The Board accepts that the Veteran experienced functional impairment and pain. See DeLuca. However, neither the lay nor medical evidence reflects the functional equivalent of limitation of motion or incapacitating episodes required to warrant the next higher evaluation. The Board therefore finds that the current 10 percent evaluation is appropriate for the Veteran’s lumbar spine disability. 5. Entitlement to higher evaluations for migraine headaches, rated as noncompensably disabling prior to May 14, 2015, and as 50 percent disabling from that date The Veteran seeks higher evaluations for his migraine headaches. Migraine headaches warrant a noncompensable evaluation where there are attacks less frequently than one in two months. A 10 percent evaluation is warranted where there are characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent rating is assigned with characteristic prostrating attacks occurring on an average once a month over last several months. A maximum 50 percent rating may be assigned when there are very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124, Diagnostic Code 8100. On VA examination in September 2012, the diagnosis was migraines. The Veteran reported that he used over the counter medication. He endorsed constant head pain, pulsating or throbbing pain, and pain on both sides of his head. He also endorsed sensitivity to light. He indicated that duration of typical head pain was less than one day. The examiner indicated that on average, the Veteran had prostrating attacks more frequently than once per month over the last several months, but that he did not have very frequent prostrating and prolonged attacks of migraine headache pain. He indicated that the headache condition did not impact the Veteran’s ability to work, noting the Veteran’s report that he had never had to miss work due to headaches. The report of a May 2015 examination completed by a private physician indicates the Veteran’s report of worsening of his headaches over the years. The provider noted that the Veteran had characteristic prostrating attacks of migraine headache pain more frequently than once per month. He specified that the Veteran had migraines three to four times per month, lasting two to three days. He indicated that the Veteran was incapacitated from six to twelve days per month. Having reviewed the record, the Board concludes that, for the period prior to May 14, 2015, a 30 percent evaluation is warranted for the Veteran’s migraine headaches. In this regard, the 2012 VA examiner indicated that the Veteran had characteristic prostrating attacks of migraine pain, on average, more than once per month. This disability pattern more closely approximates the criteria for the higher, 30 percent evaluation. However, the evidence pertaining to this period does not demonstrate very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. As such, the criteria for the higher 50 percent evaluation are not met for this earlier period. For the period from May 14, 2015, the Veteran is in receipt of a 50 percent evaluation for his migraines. This is the maximum available for headache disability, and fully contemplates the Veteran’s symptomatology. In this regard, the private provider who examined the Veteran in May 2015 indicated that the Veteran was not working, but stated that the Veteran was incapacitated due to his headaches between six and twelve days per month. Thus, for this period, the current 50 percent evaluation for migraines is appropriate. 6. Entitlement to an evaluation higher than 70 percent for mood disorder not otherwise specified (NOS) The Veteran asserts that his psychiatric disorder is manifested by symptoms that are more severe than reflected by the current 70 percent evaluation. Under 38 C.F.R. § 4.130, the General Rating Formula for Mental Disorders allows a 70 percent evaluation when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term “psychosis” to remove outdated references to the DSM-IV and replace them with references to the recently updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). The AOJ certified the Veteran’s appeal to the Board in in October 2016; therefore, the claim is governed by DSM-V. Given the significant overlap in the symptoms of disorders listed in the DSM-IV, all mental health disorders are evaluated according to the General Rating Formula for Mental Disorders. § 4.130. The “such symptoms as” language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means “for example” and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, “[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous.” Id. The Court went on to state that the list of examples “provides guidance as to the severity of symptoms contemplated for each rating.” Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. VA is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The reasonable doubt doctrine dictates that all symptoms be attributed to the veteran’s service-connected disability. See Mittleider, 11 Vet. App. at 181. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan at 442-3 (2002). However, a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration, and that such symptoms have resulted in the type of occupational and social impairment associated with that percentage. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). An October 2010 VA outpatient psychiatry note reflects the Veteran’s report that he was not doing well with anger. He indicated that he had quit a job because he could not tolerate the supervisors. He indicated that he had just finished the night shift of his current job. Mental status examination revealed normal volume and tone of speech. The Veteran was clean and hygienic. The provider noted that the Veteran’s mood was better, with less irritability, and that his thought processes and content were significantly better than previously. Recent and remote memory were normal. The Veteran denied suicidal thoughts, plans, or intent. Insight and judgement were adequate and improved. The diagnosis was bipolar disorder not otherwise specified (NOS). In January 2011, the Veteran indicated that he had stopped medication for mood swings and anger dyscontrol. He complained of racing thoughts and problems with anger control. The provider noted that the Veteran was noncompliant with medication. On mental status examination, the Veteran was clean and hygienic. Speech demonstrated improved modulation, and was of normal volume and tone. Thought processes and content were noted to be significantly better. Recent and remote memory were normal. The Veteran denied suicidal thoughts, plans, or intent. Insight and judgement were adequate and improved. The diagnosis was bipolar disorder NOS. Similar findings were reported in February 2011, and the provider noted that the Veteran had returned to taking his psychotropic medication. In May 2011, the Veteran reported a weary mood; affect was noted to be congruent to mood. The provider, a social worker, indicated that the Veteran was scheduled to see the clinic psychiatrist, and was encouraged to be very specific about vegetative symptoms of depression. In August 2011, the Veteran was seen by the clinic psychiatrist. He was casually dressed and had adequate hygiene. He was cooperative. His speech was of normal rate, volume, and tone. Her was alert and oriented. His mood was euthymic and affect was congruent. There were no thought, perceptual, or cognitive deficits observed. The Veteran denied suicidal and homicidal ideation or plans. On psychiatric evaluation in August 2012 for Social Security Administration (SSA) purposes, the Veteran’s history was reviewed. He denied suicidal ideation. He also denied hallucinations. He endorsed sleep disturbance. He described his mood over the previous month as depressed. He stated that he generally preferred to be by himself. He stated that he had been testy, and that he was unhappy with life in general. He denied panic attacks and crying spells. On mental status examination, the Veteran was oriented and alert. He maintained good eye contact and did not display tics or tremors. Speech was normal, with coherent responses. Thought processes were clear and logical. Memory was normal. Mood appeared depressed, and affect was mildly blunted. There was no evidence of exaggerating or minimalizing symptoms. With respect to work history, the Veteran reported that his most recent job was working as a welding trainee for six weeks, but that it did not work out because he could not get along with others at work. He related that he worked for 16 years as a postal worker but that he retired so he could move closer to his mother and help her with her health care needs. He indicated that prior to that, he was in the military for 20 years. He denied ever being fired or let go from a job. With respect to current functioning, he stated that he managed his medications with little or no difficulty, and that he managed his financed with some difficulty. He stated that he could prepare simple meals but that he did not have the energy or motivation to perform house work. On VA examination in September 2013, the diagnosis was mood disorder NOS. The examiner noted that the Veteran had symptoms of depression and anxiety, as well as significant anger and irritability with low frustration tolerance. She indicated that psychosocial problems included social isolation, and dealing with the chronic effects of worsening physical and mental health conditions. She concluded that the Veteran had occupational and social impairment with deficiencies in most areas. She identified depressed mood, anxiety, suspiciousness, panic attacks more than once per week, near continuous panic, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and intermittent inability to perform activities of daily living. In April 2014, the Veteran was noted to have a somewhat scruffy appearance. He was cooperative, but with impaired social graces. Thought processes were organized, linear, and goal directed. There were no paranoid or grandiose thoughts noted. His mood was dysphoric, with congruent affect. Concentration was good. Abstract thinking was good. Judgment was good and insight was adequate. He denied suicidality and homicidality. The diagnosis was depressive disorder (bipolar etiology). In October 2014, the Veteran’s appearance was scruffy. Eye contact was poor, and the Veteran was noted to be angry, with poor social behavior. He was alert and oriented. Thought process was goal directed. Mood was dysphoric, with labile affect. No perceptual disturbances were noted. Speech was not incoherent. Memory was adequate, concentration and judgment were poor, and insight was impaired. The diagnosis was depressive disorder (bipolar etiology). The psychiatrist noted that upon report of being ready to give up, she suggested inpatient treatment for mood stabilization. She indicated that the Veteran refused and walked out. She stated that the Veteran appeared to be mentally competent to decide to refuse the treatment plan offered. In April and May 2016, the Veteran’s hygiene was adequate, and he was cooperative. Speech was of normal rate, volume, and tone. He was alert and oriented. Mood was euthymic with congruent affect. There were no thought, perceptual, or cognitive deficits observed. The Veteran denied suicidal and homicidal ideation and plan. He reported that his mood was down. He indicated that he had good relationships with his daughter, mother, and a brother, but that he had difficult relationships with other siblings. He endorsed irritability for the previous several days, but noted better sleep recently. Having carefully reviewed the evidence of record, the Board concludes that a higher evaluation is not warranted for the Veteran’s psychiatric disorder. The Secretary, acting within his authority to “adopt and apply a schedule of ratings,” chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary’s use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran and disorder, and the effect of those symptoms on the claimant’s social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). The Board acknowledges that evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (1992). During the appellate period, symptoms attributable to mood disorder NOS included anxiety, problems with anger control, depression, sleep disturbance, and impairment of insight and judgment. While the Board accepts that the Veteran’s psychiatric disorder affects his functioning, the objective evidence of record does not demonstrate total occupational and social impairment. At no time has the evidence demonstrated delusions or hallucinations, grossly inappropriate behavior, suicidal or homicidal ideation, disorientation, or profound memory loss that would support a higher evaluation. While the Veteran has reported inability to perform housework, he has not demonstrated the inability to perform activities of daily living including maintenance of minimal personal hygiene. Rather, providers have found him to be repeatedly oriented, without perceptual disturbance. Despite his reported anger management problems, he has not demonstrated impaired impulse control such as unprovoked irritability with periods of violence, and he maintains some social relationships. In sum, it cannot be said that the evidence as a whole for the appellate period reflects total occupational and social impairment. As such, the Board concludes that the current evaluation of 70 percent is appropriate for the Veteran’s mood disorder NOS. Effective Dates Section 5110(a), title 38, United States Code, provides that “[u]nless specifically provided otherwise in this chapter, the effective date of an award based on an original claim... of compensation... shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor.” The implementing regulation, 38 C.F.R. § 3.400, similarly states that the effective date of service connection “will be the date of receipt of the claim or the date entitlement arose, whichever is the later.” When an application for disability compensation is received within one year of the date of the veteran’s discharge or release from service, the effective date of such award shall be the day following the veteran’s release. 38 U.S.C. § 5110(b)(1) (2012). The VA administrative claims process recognizes formal and informal claims. A formal claim is one that has been filed in the form prescribed by VA. 38 U.S.C. § 5101(a) (2012); 38 C.F.R. § 3.151(a) (2017). An informal claim may be any communication or action indicating an intent to apply for one or more benefits under VA law. Thomas v. Principi, 16 Vet. App. 197 (2002); 38 C.F.R. §§ 3.1(p), 3.155(a) (2017). 7. Entitlement to an effective date prior to March 18, 2013 for the grant of service connection for mood disorder NOS The Veteran’s informal claim of entitlement to service connection for a psychiatric disorder was received on March 18, 2013. While he indicated in his July 2014 notice of disagreement that he disagreed with the effective date assigned, he has provided no argument as to this issue. The pertinent and undisputed facts in this case are that the Veteran submitted his initial claim of entitlement to service connection for a psychiatric disorder on March 18, 2013. Review of the record reveals that there are no prior documents that can be construed as a claim, informal claim, or an intent to file a claim of entitlement to service connection for a psychiatric disorder. Under the law, the earliest effective date and the appropriate effective date in this case is March 18, 2013, the date of receipt of the Veteran’s claim for service connection. 8. Entitlement to an effective date prior to August 7, 2012 for the grant of service connection for tinnitus The Veteran’s informal claim of entitlement to service connection for tinnitus was received on August 7, 2012. The pertinent and undisputed facts in this case are that the Veteran submitted his initial claim of entitlement to service connection for a psychiatric disorder on March 18, 2013. Review of the record reveals that there are no prior documents that can be construed as a claim, informal claim, or an intent to file a claim of entitlement to service connection for a psychiatric disorder. Under the law, the earliest effective date and the appropriate effective date in this case is March 18, 2013, the date of receipt of the Veteran’s claim for service connection. TDIU Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. If the schedular rating is less than total, a total disability evaluation may be assigned based on individual unemployability if a Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that he has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16(a). Effective March 18, 2013, the effective date assigned to the grant of service connection for mood disorder NOS, the Veteran met the objective criteria under 38 C.F.R. § 4.16 for consideration of TDIU. Moreover, the Board concludes that TDIU is warranted in this case. In this regard, the record reflects that the Veteran’s service connected mood disorder is productive of problems with anger management and irritability. He has reported that he last worked as a welding trainee, but that he left the job because he was unable to get along with his supervisors. The psychiatric treatment record consistently shows that the Veteran’s irritability and anger were prominent among his complaints, and that he preferred to remain isolated because he did not get along with others. Moreover, the Veteran’s migraine headaches, evaluated as not less than 30 percent disabling for the period of this appeal, are also shown to negatively affect his ability to follow a substantially gainful occupation. In weighing the lay and medical evidence of record, the Board finds that the evidence is in relative balance as to whether the Veteran is rendered unable to obtain and maintain a substantially gainful occupation as the result of his service-connected disabilities. As such, entitlement to TDIU is warranted.  REASONS FOR REMAND 1. Entitlement to service connection for a respiratory disability Service treatment records indicate that the Veteran underwent treatment during service for cough, upper respiratory infection, pharyngitis, and bronchiolitis. A chest X-ray in December 1982 demonstrated scattered calcified granulomata. A July 1987 chest X-ray was taken after the Veteran presented with inspiratory rales. The findings were old granuloma disease and no acute cardiopulmonary disease. On periodic examination in January 1988, the examiner noted an inspiratory wheeze in the left lung, which he suggested was related to cigarette smoking. He noted that chest X-ray indicated old granulomatous disease. Chest X-ray in July 1990 revealed an old nodule in the right upper lobe. The Veteran’s lungs were otherwise hyperlucent and clear. A January 2012 VA treatment record indicates an irregular right lung nodule; the provider noted that neoplasia was not excludable, and recommended CT scan. Because there are notations indicating granulomatous disease during service, and post-service records indicate a right lung nodule, the Board concludes that an examination is necessary to determine whether there is a diagnosis associated with the current findings, and if so, whether such is related to findings in service. 2. Entitlement to separate evaluations for lower extremity radiculopathy associated with lumbar strain As noted above, pursuant to the General Rating Formula for evaluating disabilities of the spine, associated neurologic abnormalities are to be evaluated separately under the appropriate diagnostic codes. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). On VA spine examination in September 2012, muscle strength testing was 5/5 throughout. Reflexes and sensory were normal. Straight leg raising test was negative. There was no evidence of IVDS. The examiner noted that there was radiculopathy in the form of mild intermittent pain, but no other signs or symptoms of radiculopathy. He did not indicate the nerve roots involved. Subsequently in the examination report, when asked to indicate the severity of radiculopathy and the side affected, he indicated that neither side was affected. Based on this report, it is unclear whether there are in fact objective neurologic abnormalities associated with the Veteran’s lumbar strain. An examination is necessary to address this question. 3. Entitlement to an evaluation higher than 10 percent for supraventricular tachycardia The Veteran was most recently afforded a heart examination in September 2012. Since then, evidence concerning subsequent treatment have been added to the record. Specifically, a March 2014 VA cardiology consultation report indicates that the Veteran was hospitalized at Cookeville Regional Medical Center, where he underwent left heart catheterization. The VA provider noted that the Veteran had lower extremity edema that improved with diuretics. It is unclear whether any of these manifestations or findings are related to the Veteran’s service-connected supraventricular tachycardia. An examination is necessary to address this question. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed respiratory disability. The claims file must be made available to the examiner. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. Following review of the record and examination of the Veteran, the examiner should provide an opinion with respect to whether it is at least as likely as not (50 percent or more probability) that any diagnosed respiratory disability is related to any event of service. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If the examiner is unable to offer any of the requested opinions, a rationale for the conclusion that an opinion cannot be provided without resort to speculation should be provided, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. The complete rationale for any conclusion reached should be provided. 2. Schedule the Veteran for an examination to determine the nature and current severity of any objective neurological abnormalities associated with his lumbar spine disability. The examiner should provide a full description of any neurological abnormality associated with the Veteran’s lumbar spine disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In providing his or her findings, the examiner should specifically address the September 2012 examination report and the conflicting findings regarding radiculopathy. 3. Schedule the Veteran for an examination to determine the current severity of his supraventricular tachycardia. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Barone, Counsel