Citation Nr: 18147257 Decision Date: 11/05/18 Archive Date: 11/02/18 DOCKET NO. 14-28 682A DATE: November 5, 2018 ORDER Service connection for a disorder manifested by headaches and dizziness is denied. Service connection for a disorder manifested by limited use of the arms, hands, legs and feet is denied. A disability rating in excess of 20 percent for degenerative disc disease of the lumbosacral spine is denied. A compensable rating for left ear hearing loss is denied. A disability rating in excess of 10 percent prior to October 1, 2013, and 60 percent thereafter, for ischemic heart disease, is denied. REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an increased disability rating for a cervical spine disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. Entitlement to Dependents Education Assistance (DEA) benefits is remanded. FINDINGS OF FACT 1. At no time during the pendency of the claim does the Veteran have a current diagnosis of a disorder manifested by headaches or dizziness, and the record does not contain a recent diagnosis of disability prior to the Veteran’s filing of the claim. 2. At no time during the pendency of the claim does the Veteran have a current diagnosis of a disorder related to the bilateral upper extremities or bilateral lower extremities, and the record does not contain a recent diagnosis of disability prior to the Veteran’s filing of the claim. 3. Throughout the appeal period, the Veteran’s degenerative disc disease of the lumbosacral spine, residuals of injury, was manifested by forward flexion limited, at worst, to 80 degrees; was not ankylosed; and was not productive of incapacitating episodes of any kind, even when considering pain and functional impairment on use. 4. The Veteran’s left ear hearing loss was manifested by no worse than Level III hearing throughout the appeal period. 5. Prior to October 1, 2013, the Veteran’s ischemic heart disease manifested as the use of continuous medication but was not productive of a workload of greater than 5 metabolic equivalent (METs) but not greater than 7 METs, and there is no evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 6. After October 1, 2013, the Veteran’s ischemic heart disease was not manifested by a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; nor was it manifested by chronic congestive heart failure or a left ventricular ejection fraction (LVEF) of less 30 percent. CONCLUSIONS OF LAW 1. The criteria for service connection for a disorder manifested by headaches or dizziness have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for service connection for a disorder manifested by loss of use of the upper and lower extremities have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria for a disability rating in excess of 20 percent for degenerative disc disease of the lumbosacral spine, residuals of injury, are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5243 (2017). 4. The criteria for a compensable disability rating for left ear hearing loss are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.85, 4.86, Diagnostic Code 6100 (2017). 5. The criteria for an initial rating in excess of 10 percent for ischemic heart disease, prior to October 1, 2013, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005 (2017). 6. The criteria for a rating in excess of 60 percent for ischemic heart disease, after October 1, 2013, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1967 to June 1970 and from June 1972 to February 1975. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996). In addition to the elements of direct service connection, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); Wallin v. West, 11 Vet. App. 509, 512 (1998). Pertinent to any claim for service connection, such a determination requires a finding of a current disability that is related to an injury or disease in service. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). The requirement of a current disability is satisfied if the veteran has a disability at the time she files her service connection claim or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, when the record contains a recent diagnosis of disability prior to the veteran’s filing of a claim for benefits based on that disability, the report of the diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran seeks service connection for a disorder manifested by headaches and dizziness. He also seeks service connection for a disorder characterized as limited use of his arms, hands, legs and feet. He asserts that he developed these disorders as a result of his service-connected degenerative disc disease of the spine. The Veteran underwent a VA back examination in December 2010. At that time, no secondary neurological or other such disabilities were noted. At a May 2012 VA examination, the examiner specifically found no evidence to support a diagnosis of a disorder manifested by limited use of the arms, legs, hands and feet. He further concluded that, despite subjective complaints of headaches and dizziness, there was no evidence to support a diagnosis of such a disorder. A review of the record shows no diagnosis of any such disorder at any time. Based on the evidence of record, the Board finds that the Veteran’s claim for entitlement to service connection for disorders manifested by limited use of the bilateral upper and lower extremities, and a disorder manifested by headaches and dizziness, must be denied. In making this determination, the Board highlights that the first element required for service connection is the existence of a current disability. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303; Pond v. West, 12 Vet. App. 341 (1999). Without a current disability, service connection cannot be granted. See McClain, supra; Brammer, supra. The Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465 (1994). Here, while the Veteran and his wife are capable of describing symptoms they experienced or observed, the Board finds that the question regarding the diagnosis of neurological disorders is complex in nature and within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134 (1994). Specifically, the diagnosis of specific neurological disorders concern an internal physical process extending beyond an immediately observable cause-and-effect relationship, and requires the administration and interpretation of specialized testing. In the instant case, there is no suggestion that the Veteran or his wife has developed such expertise required to diagnose neurological or musculoskeletal disorders, or to determine the causation of such. Without the appropriate medical training and expertise to competently make a medical diagnosis, their lay assertions in this regard have no probative value. In short, in the absence of persuasive probative evidence demonstrating any current disability, a preponderance of the evidence is against the Veteran’s claim. Accordingly, because the first element required for service connection—presence of a current disability—has not been satisfied, the Veteran’s claim of entitlement to service connection for a disorder manifested by headaches and dizziness and a disorder characterized as limited use of his arms, hands, legs and feet must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). See 38 C.F.R. Part 4 (2017). Ratings for service-connected disabilities are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Rating Schedule, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Individual disabilities are assigned separate diagnostic codes. 38 C.F.R. § 4.27 (2017). When a question arises as to which of two disability evaluations applies under a particular diagnostic code, 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. Consideration must be given to increased evaluations under other potentially applicable diagnostic codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the veteran experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2017); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the United States Court of Appeals for Veterans Claims (Court) explained that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40 ), less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45 ). Functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. However, pain, itself, does not constitute functional loss and is just one factor to be considered when evaluating functional impairment. Mitchell, 25 Vet. App. at 33 and 43. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. Degenerative disc disease lumbar spine, residuals of injury The Veteran contends that he is entitled to a higher rating for his service-connected degenerative disc disease of the lumbosacral spine, residuals of injury (hereinafter, “back disability”). His back disability is rated as 20 percent disabling under Diagnostic Code 5243. Under VA’s Rating Schedule, disabilities of the spine are to be evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.2. See 38 C.F.R. § 4.71a, The Spine, General Rating Formula for Diseases and Injuries of the Spine, Note (6) (2017). The General Rating Formula provides the same rating criteria for Diagnostic Codes 5235 through 5243. A 20 percent disability rating for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, 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 disability rating is assigned for forward flexion of the thoracolumbar spine of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of the entire spine. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. See Note (1). Normal ranges of motion of the thoracolumbar spine are forward flexion from 0 degrees to 90 degrees, and 0 degrees to 30 degrees for extension, left and right lateral flexion, and left and right lateral rotation. See Note (2) and Plate V. Combined range of motion of the thoracolumbar spine refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. See Note (2). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphasia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. See Note (5). Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Intervertebral Disc Syndrome (IVDS) is evaluated on the total duration of incapacitating episodes over the past 12 months. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. See Note (1). As noted above, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and 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. The United States Court of Appeals for Veterans Claims (Court) has held that the final sentence of § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). In this case, remand is not necessary to obtain another examination regarding the lumbar spine, as the question for a higher rating is whether there is ankylosis present, and a higher rating could not be awarded based on range of motion findings. The Veteran underwent a VA spine examination in December 2010. At that time, he reported chronic moderate back pain, with stiffness, weakness, lack of endurance, and fatigability. The Veteran described flare-ups in which he experienced increased pain and tightness. On examination, forward flexion was measured at 80 degrees. Right and left lateral flexion was noted at 25 degrees, with rotation at 30, after repetitive use testing. Range of motion was limited by pain. Negative straight leg raise was negative, and there was mild tenderness to palpation. The examiner concluded that there were no associated bladder or bowel dysfunction, nor any prescribed bed rest or treatment due to a spinal condition during the previous 12 months. In October 2013, the Veteran was provided with a VA spine examination. He reported back pain of longstanding duration. The Veteran reported flare-ups which occurred after walking, bending or exercising. On examination, forward flexion was measured at 80 degrees, with no objective evidence of painful motion. Extension ended at 20 degrees, and flexion at 25. Range of motion was determined to be normal for age and body habitus. Range of motion after repetitive use testing was 80 degrees forward flexion, 20 degrees extension, and 25 degrees for bilateral lateral flexion. There was no additional limitation in range of motion for the spine following testing. Straight leg raising was negative, and there was no radiculopathy present. Neurological abnormalities such as those related to the bladder or bowel were absent. No IVDS was found. In multiple statements to VA, the Veteran described back pain that he treated with medication. His wife described her observations of the Veteran’s difficulties in getting dressed due to his back pain. Here, there is no evidence that the range of motion of the Veteran’s thoracolumbar spine has met the criteria for a 40 percent rating; that is, at no point has forward flexion been found to be at 30 degrees or less. Additionally, there has been no evidence of ankylosis at any point during the appeal. As noted in the December 2011 rating decision on appeal, the Veteran’s 20 percent rating is based on criteria in effect at the time of the original June 1999 grant of service connection, and his current symptoms do not meet the present criteria for a 20 percent rating. It thus follows that the criteria for a 40 percent rating are not met. VA examination reports, VA medical treatment records, and the Veteran’s lay statements do not indicate that his back disability showed any signs of forward flexion of 30 degrees or less for the thoracolumbar spine, and at no point has an examiner or treating physician diagnosed favorable ankylosis of the entire thoracolumbar spine, or unfavorable ankylosis of the entire spine. Thus, the Board finds that the Veteran’s symptoms do not warrant a rating in excess of 20 percent. The Board has also considered whether a disability rating higher than 20 percent is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. Although the Veteran’s symptoms included pain on movement, the VA examination reports of record noted that, despite pain which caused such loss, the Veteran had forward flexion to at least 80 degrees even after three repetitions of repetitive-use testing. In sum, even considering the effects of pain, the Veteran retained ranges of motion in the thoracolumbar spine. In other words, any additional limitation due to pain does not more nearly approximate a finding of forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Accordingly, the 20 percent rating contemplates the functional loss due to pain and less movement. There is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness or incoordination for this period of the appeal. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra. Consideration has also been given to the potential application of the other diagnostic codes for disabilities of the spine. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. A higher rating is not warranted under Diagnostic Code 5243. Even if the Veteran were found to have IVDS, there is no medical evidence of incapacitating episodes having a total duration of at least four weeks, or physician-prescribed bed rest, which is the requirement for an incapacitating episode. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note 1. It is acknowledged that the examiners did not provide an estimated loss of motion during flare-ups. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). However, the Board finds that additional development solely for this purpose would serve only to delay the claim. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). As noted above, the examination reports contain evidence regarding the frequency, severity, and duration of the Veteran’s pain level during flare-ups, per his report. The Board finds such information pertinent and useful when evaluating the disability picture concerning the Veteran’s service-connected back disability. As such, the Board finds that it has adequate competent evidence to assess the Veteran’s left knee disability picture. Finally, the Board has considered whether additional separate ratings for associated objective neurological abnormalities are warranted. In this regard, the evidence does not show that there are additional associated objective neurological abnormalities, to include bladder and/or bowel impairment, related to the Veteran’s back disability. Both VA examiners who evaluated the Veteran in connection with the appeal before the Board determined that no such disabilities existed. Further, to the extent that the Veteran asserts that he developed neurological disabilities of the bilateral upper and lower extremities due to his back disability, as noted above, no such disabilities have been diagnosed at any point pertinent to the appeal. In sum, the preponderance of the evidence is against the award of a rating in excess of 20 percent for the Veteran’s back disability and the appeal is denied. As a preponderance of the evidence is against the award of an increased evaluation for this period of the appeal, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. Sensorineural hearing loss, left ear The Veteran asserts that he is entitled to a higher disability rating for left ear hearing loss, currently rated as noncompensable under Diagnostic Code 6100. Ratings of hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second. To rate the degree of disability for service-connected hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85 (h), Table VI. In order to establish entitlement to a compensable rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average pure tone decibel loss are met. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. These results are then charted on Table VI, Table VIA, in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII, as set out in the Rating Schedule. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. The Veteran underwent a VA audiological examination in January 2011. This examination revealed the following puretone thresholds, in decibels (dB), for the frequencies 500, 1000, 2000, 3000, 4000 Hertz: 15, 30, 45, 55, and 50, respectively, in the left ear. The average for the left ear was 45 dB. Speech audiometry revealed speech recognition ability of 80 percent in the left ear. The examiner diagnosed the Veteran with normal sloping to moderately severe sensorineural hearing loss. Using Table VI, these audiometric test results equate to Level III hearing in the left ear. 38 C.F.R. § 4.85. Utilizing Table VII, such a result meets the criteria for a noncompensable rating. Id. With regard to the functional impact of his hearing loss, the examination report indicates that the Veteran had difficulty hearing conversation due to background noise. In October 2013, the Veteran underwent a VA audiological examination. This examination revealed the puretone thresholds for the frequencies 500, 1000, 2000, 3000, 4000 Hertz as 10, 25, 45, 55, and 45, respectively, in the left ear. The average for the left ear was 43 dB. Speech audiometry revealed speech recognition ability of 94 percent in the left ear. The examiner diagnosed the Veteran with sensorineural hearing loss. Using Table VI, these audiometric test results equate to Level I hearing in the left ear. 38 C.F.R. § 4.85. Utilizing Table VII, such a result meets the criteria for a noncompensable rating. Id. With regard to the functional impact of his hearing loss, the examiner concluded that while the Veteran reported an inability to think clearly due to his hearing loss, based on testing results he would be able to effectively communicate in most listening situations. Finally, in October 2017, the Veteran again underwent VA audiological testing. This examination revealed the following puretone thresholds for the frequencies 500, 1000, 2000, 3000, 4000 Hertz: 10, 30, 55, 55, and 65, respectively, in the left ear. The average for the left ear was 51.25 dB. Speech audiometry revealed speech recognition ability of 100 percent in the left ear. The examiner diagnosed the Veteran with bilateral sensorineural hearing loss. Using Table VI, these audiometric test results equate to Level I hearing in the left ear. 38 C.F.R. § 4.85. Utilizing Table VII, such a result meets the criteria for a noncompensable rating. Id. With regard to the functional impact of his hearing loss, the examination report indicates that his hearing impacted his occupation and other daily activities in that the Veteran tended to isolate himself due to his hearing disability. Based on the VA audiological examinations of record, the Board finds that the Veteran’s hearing was no worse than Level III in the left ear. In applying the criteria in Table VII, the Veteran is not entitled to a compensable rating for his left ear hearing loss at any point during the appeal. The Board has considered whether additional staged ratings are appropriate for the Veteran’s service-connected left ear hearing loss; however, the Board finds that his symptomatology has been stable for the disability throughout the appeal. Therefore, assigning additional staged ratings for the disability is not warranted. To the extent that the Veteran contends that his hearing loss is more severe than currently evaluated, the Board observes that the Veteran, while competent to report symptoms such as difficulty hearing voices or in crowds and understanding speech when around multiple people, he is not competent to report that his hearing acuity is of sufficient severity to warrant a higher evaluation under VA’s tables for rating hearing loss disabilities because such an opinion requires medical expertise (training in evaluating hearing impairment), which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In reaching its conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the assignment of any higher rating, that doctrine is not for application and the claim for a compensable disability rating must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102; Gilbert, supra. Ischemic heart disease The Veteran’s ischemic heart disease (IHD) is currently rated under Diagnostic Code 7005. Under that code, a 10 percent rating is warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or where continuous medication is required. For a 30 percent rating, the evidence must show that a workload of greater than 5 METs but not greater than 7 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year; or where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure; or where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, 7005. The Veteran’s IHD is rated as 10 percent disabling prior to October 1, 2013, and 60 percent thereafter. He asserts that he is entitled to a higher rating at all points pertinent to the appeal. Prior to October 1, 2013 In December 2010, the Veteran underwent a VA examination in relation to his claim. At that time, it was noted that he took multiple medications to treat his IHD. No congestive heart failure was found. Exercise testing showed mildly reduced LVEF associated with mild global hypokinesis of the left ventricular walls. Diagnostic testing showed no cardiac hypertrophy or dilatation. METs testing showed no symptoms with any level of activity as a result of IHD. The examiner concluded that there would be no functional impact on the Veteran’s ability to work, due to IHD. Private cardiac treatment records from this time period show continuous medication used to treat the Veteran’s IHD. An April 2012 treatment note indicated that the Veteran’s LVEF was 60 percent. Based on this evidence, the Board finds that a higher disability rating is not warranted for the period prior to October 1, 2013. The record shows that the Veteran required the use of the medication for his ischemic heart disease, without any symptoms requiring an estimation of METs. Therefore, the 10 percent rating criteria are met. The record does not establish that there was a workload of greater than 5 METs but not greater than 7 METs or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A rating in excess of 10 percent for this period is therefore not warranted. After October 1, 2013 In October 2013, the Veteran underwent a VA examination. At that point, he was no longer taking medication continuously for IHD. Congestive heart failure was absent. METs testing showed dyspnea and fatigue, with a METS level greater than 3 to 5. There was no evidence of cardiac hypertrophy or dilation, and LVEF was 60 percent. A May 2015 VA cardiology treatment note showed the Veteran had normal left ventricular systolic function with 60 percent LVEF. No congestive heart failure was found. A May 2016 private treatment note indicated that testing showed LVEF of 63 percent. Based on this evidence, the Board finds that a higher disability rating is not warranted for the period after October 1, 2013. The next highest rating of 100 percent requires chronic congestive heart failure, or; workload of 3 METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope; or, LVEF of less than 30 percent, is to be rated as 100 percent disabling. Upon review of the claims file, none of these criteria were met between after October 1, 2013. The objective evidence of record has revealed LVEFs that are consistently greater than 30 percent and an estimated workload greater than 3 to 5 METs. There was no evidence of cardiac hypertrophy, dilation, or congestive heart failure. Repeated VA treatment notes specifically ruled out the presence of congestive heart failure. The Veteran has not identified or submitted any evidence demonstrating that his IHD was of such a severity to warrant a 100 percent rating under the relevant schedular criteria. Accordingly, a rating greater than 60 percent is not warranted during this time period. See 38 C.F.R. § 4.104, DC 7005 (2017). In assessing the severity of the Veteran’s IHD throughout the entire appeal period, the Board has considered his assertions regarding his symptoms, which he is certainly competent to provide. See, e.g. Layno, supra; Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings require medical findings that are within the province of trained medical professionals. See Jones, supra. As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. In reaching these conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the assignment of any higher rating, that doctrine is not for application and the claim for a higher disability rating for IHD must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102; Gilbert, supra. REASONS FOR REMAND PTSD The Veteran asserts that he is entitled to service connection for PTSD, as a result of his experiences during active military service. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f). If the evidence establishes a veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, his or her lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f)(2). Where the claimed stressor is not related to combat, the Veteran’s lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborates the Veteran’s account as to the occurrence of the claimed stressor. See 38 U.S.C. § 1154 (b); 38 C.F.R. § 3.304 (d), (f); Cohen v. Brown, 10 Vet. App. 128 (1997). Evidence denoting participation in combat includes award of decorations such as the Combat Action Ribbon, Combat Infantryman Badge (CIB), Purple Heart Medal, and decorations such as the Bronze Star Medal that have been awarded with a Combat “V” device. Pursuant to 38 C.F.R. § 3.304 (f)(3), if a stressor claimed by a veteran is related to his or her fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. The “fear of hostile military or terrorist activity” is determined by whether the veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and that the veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. In a July 2018 evaluation performed by a private psychologist, submitted by the Veteran’s attorney in August 2018, the Veteran reported stressors involving fear of hostile military and terrorist activity, including artillery and rocket attacks, as well as snipers and ground attacks. He reported a specific incident in which he was called away from a bunker in Phu Bai and the bunker was subsequently attacked, resulting in the death of many soldiers. The Veteran also described seeing multiple dead Vietnamese civilians and dead and wounded American soldiers. The Veteran’s DD Form 214 does not document receipt of any award that would definitively demonstrate that the Veteran engaged in combat. Additionally, the Veteran was provided with a VA examination in February 2011, at which the examining VA psychiatrist found that the Veteran did not meet the criteria for PTSD. However, the February 2011 examination report does not reflect that the examiner considered those events reported by the Veteran in 2018. While the private psychologist concluded that the Veteran clearly met all the DSM-5 criteria for PTSD, without a verified stressor, 38 C.F.R. § 3.304 (f)(3) specifies that the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor if a VA psychiatrist or psychologist (or a psychiatrist or psychologist with whom VA has contracted), confirms that the claimed stressor(s) involving a fear of hostile military or terrorist activity is adequate to support a diagnosis of PTSD and that the Veteran’s symptoms are related to the claimed stressor(s). As this opinion came from a private psychiatrist, while probative, it is insufficient to confirm the in-service occurrence of the Veteran’s reported stressors. On remand, the Veteran should be provided with an additional VA examination which considers the full evidence of record and specifically addresses the prior diagnoses of PTSD and the Veteran’s reported stressors in the context of determining whether the stressors involving fear of hostile military and terrorist activity are sufficient to support a diagnosis of PTSD. Further, there is no indication that efforts have been made to verify the Veteran’s reported stressors. The July 2018 private evaluation contains multiple details such as the Veteran’s unit assignment, and the locations in which his stressors occurred. While the Veteran did not provide exact dates, the Board notes that his DD Form 214 specifies that the Veteran’s service in the Republic of Vietnam spanned from July 1968 to July 1969, which would limit the dates that would need to be covered in any subsequent request for verification. Neck The Veteran last underwent a VA examination of his cervical spine in October 2013. However, a new precedential opinion that directly affects this case has been issued by the Court, in which it held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. See Correia, supra. Thus, the Court’s holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. A review of the claims file reveals that the previous VA examination report includes only active range of motion findings and does not include range of motion findings for passive range of motion. As the previous examination reports do not fully satisfy the requirements of Correia and 38 C.F.R. § 4.59, a new examination is necessary to decide the claim. TDIU In June 2013, the Veteran submitted a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, indicating that he was unable to work due to his service-connected disabilities. The RO acknowledged the claim for TDIU by providing notice under the Veterans Claims Assistance Act in August 2013. After a brief period of development in October 2013, the Regional Office took no further action on the Veteran’s claim. As a TDIU claim is part of an increased rating claim when raised by the record, and in this case it has not yet been adjudicated below, the TDIU claim has been added to this appeal, and should be adjudicated upon remand. 38 U.S.C. § 7104 (a) (2012); 38 C.F.R. § 38 C.F.R. § 20.101(a) (2017); Rice v. Shinseki, 22 Vet. App. 447 (2009). DEA Basic eligibility for DEA exists if a veteran, inter alia, was discharged from service under conditions other than dishonorable, and has a permanent total service-connected disability. Here, the Veteran has pending appeals concerning disabilities which are potentially permanent and total, as well as a claim for TDIU, which are being remanded for further development. Thus, his DEA benefits claim is inextricably intertwined with those claims, as their adjudication may affect the DEA claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); see also Ephraim v. Brown, 5 Vet. App. 549, 550 (1993) (inextricably intertwined claims should be remanded together). Therefore, further consideration of entitlement to DEA must be deferred. The matters are REMANDED for the following action: 1. Complete all necessary development to attempt to verify the Veteran’s reported PTSD stressors, to include contacting Joint Services Records Research Center to provide any available information which might corroborate the Veteran’s alleged in-service stressors. The Board notes that the Veteran described a number of stressors in a July 2018 private PTSD examination. Thereafter, make a determination as to whether the Veteran’s claimed stressors have been verified. 2. After completing the above, schedule the Veteran for an additional VA psychological examination with a VA psychiatrist or psychologist or comparable contractor to determine the nature and etiology of any current acquired psychiatric disorder, to specifically include PTSD. Any verified stressor(s) should be reported to the examiner. The examiner should then determine whether it is at least as likely as not (50 percent or greater probability) that a) one or more of the Veteran’s stressors is adequate to support a diagnosis of PTSD; b) that the Veteran’s symptoms are related to this stressor; and c) that this stressor involved fear of hostile military or terrorist activity. 3. Schedule the Veteran for a VA orthopedic examination to determine the nature, severity and extent of his current cervical spine pathology. (Continued on the next page)   4. Adjudicate the Veteran’s TDIU and DEA claims. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jeremy J. Olsen, Counsel