Citation Nr: 18147491 Decision Date: 11/06/18 Archive Date: 11/05/18 DOCKET NO. 15-31 646 DATE: November 6, 2018 ORDER Entitlement to service connection for tendonitis is denied. Entitlement to service connection for sore feet is denied. Entitlement to service connection for hemorrhoids is denied. Entitlement to service connection for hypertension (HTN), which was previously described as high blood pressure, is granted. Entitlement to an initial rating in excess of 10 percent for a bilateral hearing loss disability is denied. REMANDED Entitlement to service connection for low back pain is remanded. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. Entitlement to service connection for migraine headaches is remanded. Entitlement to service connection for a right-side ulcer with pain is remanded. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and unspecified depressive disorder, is remanded. Entitlement to service connection for claustrophobia is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to an initial rating in excess of 10 percent for left knee osteoarthritic changes (hereinafter referred to as a “left knee disability”) is remanded. Entitlement to a total disability rating for individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The weight of the evidence does not show that the Veteran has a current diagnosis of tendonitis that was incurred in, or resulted from, service, to include as caused by or related to exposure to environmental hazards. 2. The weight of the evidence does not show that the Veteran has a current diagnosis manifesting in sore feet that was incurred in, or resulted from, service, to include as caused by or related to exposure to environmental hazards. 3. The weight of the evidence does not show that the Veteran has a current diagnosis of hemorrhoids that was incurred in, or resulted from, service, to include as caused by or related to exposure to environmental hazards. 4. The evidence demonstrates that the Veteran has a current diagnosis of HTN that was incurred during active service. 5. For the entire appeal period, audiometric testing revealed average puretone threshold of 51 decibels and 76 percent speech recognition in the right ear, and average puretone threshold of 55 decibels and 72 percent speech recognition in the left ear. CONCLUSIONS OF LAW 1. The criteria to establish service connection for tendonitis are not met. 38 U.S.C. §§ 1110, 1117, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. The criteria to establish service connection for sore feet are not met. 38 U.S.C. §§ 1110, 1117, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. The criteria to establish service connection for hemorrhoids are not met. 38 U.S.C. §§ 1110, 1117, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317. 4. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for HTN are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for an initial rating in excess of 10 percent for a bilateral hearing loss disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code (DC) 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had a period of active duty for training (ACDUTRA) from May 1967 to September 1967, and of active service from November 1990 to May 1991. The Veteran initially filed separate claims of entitlement to service connection for different mental health conditions, specifically PTSD, anxiety, and depression, which were all denied. However, in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims clarified how the Board should analyze claims for PTSD and other acquired psychiatric disabilities. As emphasized in Clemons, a veteran’s claim “cannot be limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed.” Id. The Regional Office (RO) combined the anxiety and depression claims, characterizing them as an unspecified depressive disorder; but continued to keep the claim for PTSD separate. However, the Board has combined the claims and recharacterized them as set forth above. Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, 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 connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The United States Court of Appeals for Veterans Claims has held that “Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b); see also Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Patrick v. Shinseki, 668 F.3d 1325, 1329 (Fed. Cir. 2011) (to rebut the presumption of soundness in the case of a wartime veteran, the evidence must clearly and unmistakably show not only that the disorder at issue pre-existed entry into service, but clear and unmistakably show that the disorder did not undergo aggravation in or as a result of service). 38 C.F.R. § 3.304(b) states likewise, but also states “[o]nly such conditions as are recorded in examination reports are to be considered as noted.” Service connection may be also granted only for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA or injury incurred or aggravated while performing inactive duty for training (INACDUTRA). See 38 U.S.C. § 101(22), (24); 38 C.F.R. § 3.6. However, the presumption provisions of 38 C.F.R. §§ 3.307 and 3.309, as well as the presumptions of soundness and aggravation, are inapplicable to periods of ACDUTRA and INACDUTRA. Smith v. Shinseki, 24 Vet. App. 40 (2010); Donnellan v. Shinseki, 24 Vet. App. 167 (2010). Personnel records reflect that the Veteran in this case was stationed in Saudi Arabia from January 1991 to May 1991. Service connection may also be established for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability resulting from an undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016, and cannot be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). The applicable presumptive period specified in 38 C.F.R. § 3.317(a)(1)(i) has been extended several times, and currently ends December 21, 2021. See 81 Fed. Reg. 71382 (October 17, 2016). A qualifying chronic disability means a chronic disability resulting from (A) an undiagnosed illness or (B) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms. 38 C.F.R. § 3.317(a)(2)(i). The term “medically unexplained chronic multisymptom illness” means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology are not considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Examples of medically unexplained chronic multi-system illness that are defined by a cluster of signs or symptoms include: (1) chronic fatigue syndrome; (2) fibromyalgia; and (3) functional gastrointestinal disorders (excluding structural gastrointestinal diseases), such as irritable bowel syndrome. Id. Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, unlike those for “direct service connection,” there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert, supra. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 1. Entitlement to service connection for tendonitis In his February and August 2016 VA Forms 9, the Veteran stated that he was treated for tendonitis in December 1990 at Camp Santiago while on active duty, and that he continued to receive treatment for this condition. Based on a review of the evidence of record, the Board finds that the evidence weighs against findings in favor of the Veteran’s service connection claim for tendonitis as there is no evidence of a current diagnosis of such. Service treatment records (STRs) reflect that in December 1990 the Veteran was assessed with left knee posttraumatic medial collateral tendonitis. However, at his October 2015 VA examination, although the Veteran reported that he had tendonitis in his left knee, the examiner only diagnosed him with osteoarthritis changes of the left knee. There is no evidence of a current diagnosis of tendonitis. Service connection under any theory requires a current diagnosis or disability. While the Veteran reported a diagnosis of tendonitis, the evidence does not reflect a current diagnosis of such. See Brammer, 3 Vet. App. at 225. Rather, the treatment records reflect that the Veteran has osteoarthritic changes to his left knee, for which the Veteran is already service-connected. The Board considered the lay evidence in this case. As a layperson, the Veteran is competent to report matters within his own personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). As such, he is competent to report symptoms, such as pain. However, he is not competent to provide a clinical diagnosis of tendonitis, as such a determination is medical in nature and requires medical expertise to make, and there is no evidence that the Veteran has such medical training. Thus, the Veteran has not presented competent evidence showing that he has a current diagnosis of tendonitis. See 38 U.S.C. § 5107(a) (“[A] claimant has the responsibility to present and support a claim for benefits.”); Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009) (holding that it is the claimant’s general evidentiary burden to establish all elements of the claim). Additionally, as the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War, the Board must consider whether he is entitled to presumptive service connection under 38 C.F.R. § 3.317. The evidence does not demonstrate that the Veteran has an undiagnosed illness, but rather that the Veteran has osteoarthritic changes to the left knee rather than tendonitis. Moreover, a February 2015 VA Gulf War examination report reflects that the Veteran did not have any diagnosed illnesses for which no etiology was established, and that the Veteran did not report any additional signs or symptoms which may represent an “undiagnosed illness” or “diagnosed medically unexplained chronic multisymptom illness.” In summary, the Board finds that the preponderance of the evidence is against the Veteran’s service connection claim for tendonitis. 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(b); Gilbert, 1 Vet. App. at 53-56. 2. Entitlement to service connection for sore feet In his February and August 2016 VA Forms 9, the Veteran stated that he was treated for sore feet in May 1985, and that he continued to receive treatment for this condition. Based on a review of the evidence of record, the Board finds that the evidence weighs against findings in favor of the Veteran’s service connection claim for sore feet as there is no evidence of a current diagnosis manifesting in such symptoms. STRs reflect that in May 1985, the Veteran complained of a sore left foot with sharp pain and throbbing for four days. He was wearing new boots and had callus build-up on the left foot heel area. Later that month, he complained of “sore feet.” The Board notes that these records are not from a period of active service or ACDUTRA. There is no evidence of sore feet during a qualifying period of service. Additionally, at his October 2015 VA examination, the Veteran denied pain, soreness, or a foot condition on that day or as a recurrent problem. As such, there is no evidence of a current bilateral foot disability. Service connection under any theory requires a current diagnosis or disability. While the Veteran reported a diagnosis of “sore feet,” the evidence does not reflect a current bilateral foot disability. See Brammer, 3 Vet. App. at 225. Rather, the Veteran himself denied any recurrent foot disorder at the October 2015 VA examination. The Board considered the lay evidence in this case. As a layperson, the Veteran is competent to report matters within his own personal knowledge. See Layno, supra. As such, he is competent to report symptoms, such as pain or soreness. However, he is not competent to provide a clinical diagnosis involving his feet, as such a determination is medical in nature and requires medical expertise to make, and there is no evidence that the Veteran has such medical training. Thus, the Veteran has not presented competent evidence showing that he has a current diagnosis of a bilateral foot disability. See 38 U.S.C. § 5107(a); Fagan, supra. Additionally, as the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War, the Board must consider whether he is entitled to presumptive service connection under 38 C.F.R. § 3.317. The evidence does not demonstrate that the Veteran has an undiagnosed illness, but rather that the Veteran denied having a recurrent bilateral foot disorder. Moreover, as stated above, a February 2015 VA Gulf War examination report reflects that the Veteran did not have any diagnosed illnesses for which no etiology was established, and that the Veteran did not report any additional signs or symptoms which may represent an “undiagnosed illness” or “diagnosed medically unexplained chronic multisymptom illness.” In summary, the Board finds that the preponderance of the evidence is against the Veteran’s service connection claim for sore feet. 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(b); Gilbert, 1 Vet. App. at 53-56. 3. Entitlement to service connection for hemorrhoids In his February and August 2016 VA Forms 9, the Veteran stated that he was diagnosed with hemorrhoids during service, as reflect in a September 1986 form. Based on a review of the evidence of record, the Board finds that the evidence weighs against findings in favor of the Veteran’s service connection claim for hemorrhoids as there is no evidence of a current diagnosis of hemorrhoids or of an in-service incurrence. The evidence does not demonstrate a current diagnosis of hemorrhoids, nor does the Veteran contend that he currently has hemorrhoids. Service connection under any theory requires a current diagnosis or disability. See Brammer, 3 Vet. App. at 225. Regardless, the evidence also does not demonstrate an in-service incurrence of hemorrhoids. The Board notes that STRs reflect that a September 1986 examination report reflects that the Veteran had hemorrhoids. However, this examination is not from a period of active service or ACDUTRA. Rather, it was from a non-qualifying period of service. Additionally, as the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War, the Board must consider whether he is entitled to presumptive service connection under 38 C.F.R. § 3.317. The evidence does not demonstrate that the Veteran has an undiagnosed illness, but rather the Veteran contended that he had was diagnosed with hemorrhoids during service. Moreover, as stated above, a February 2015 VA Gulf War examination report reflects that the Veteran did not have any diagnosed illnesses for which no etiology was established, and that the Veteran did not report any additional signs or symptoms which may represent an “undiagnosed illness” or “diagnosed medically unexplained chronic multisymptom illness.” In summary, the Board finds that the preponderance of the evidence is against the Veteran’s service connection claim for hemorrhoids. 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(b); Gilbert, 1 Vet. App. at 53-56. 4. Entitlement to service connection for HTN The Veteran contends that service connection is warranted for his HTN. In February 2015, he stated that he was diagnosed with high blood pressure while stationed in the Persian Gulf with a blood pressure reading of 150/100. However, in his September 2015 VA Form 9, he reported that he was treated for high blood pressure during service in September 1986. Based upon the evidence of record in conjunction with the applicable laws and regulations, the Board finds the evidence demonstrates that the Veteran’s current diagnosis of HTN was incurred during active service. Turning to the evidence, STRs reflect that the Veteran had blood pressure readings of 120/92 in December 1990, 130/90 in December 1990, and 144/90 in April 1991. Private treatment records reflect a diagnosis of unspecified essential HTN since December 2014. As an initial matter, the Board notes that a September 1986 examination report reflects that the examiner noted a diagnosis of HTN and recommended treatment. However, this did not occur during a period of active service or ACDUTRA. The evidence does not indicate any blood pressure problems during the Veteran’s period of ACDUTRA. Unfortunately, the evidence does not contain an examination report at the time of entry into active duty service. As such, there is no evidence that HTN prior to enlistment in active duty service was noted. Therefore, the burden is on VA to show by clear and unmistakable evidence both that the Veteran’s HTN pre-existed active duty service and that it was not aggravated during service. See Wagner, supra. Here, the Board finds that the evidence suggesting HTN prior to active duty service is unclear as it was noted at a periodic examination report in 1986 before the Veteran’s blood pressure readings subsequently decreased. Additionally, there is no treatment record confirming the diagnosis and treatment of HTN prior to active duty service. As such, the presumption of soundness is resolved in the Veteran’s favor, and he is found to be sound at the time of enlistment. During active duty service from November 1990 to May 1991, the Veteran’s diastolic blood pressure readings ranged from 90 to 92, which are hypertensive. The systolic blood pressure readings in December 1990 and April 1991 were 130 and 144, respectively, which are also hypertensive. As such, the evidence demonstrates that the Veteran’s high blood pressure manifested during active duty service. In light of the absence of a VA examination, and after considering all of the evidence of record, the Board gives the Veteran the benefit of the doubt and finds that his HTN was incurred during active duty service. Initial Rating Claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; Gilbert, 1 Vet. App. at 49. 5. Entitlement to an initial rating in excess of 10 percent for a bilateral hearing loss disability The Veteran contends that the severity of his bilateral hearing loss disability warrants a higher rating. The Board finds that the weight of the evidence is against an initial in excess of 10 percent for the Veteran’s service-connected bilateral hearing loss disability. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. In this case, the Veteran’s service-connected bilateral hearing loss disability is evaluated as 10 percent disabling from August 12, 2013, under 38 C.F.R. § 4.86, DC 6100. When evaluating service-connected hearing impairment, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned in audiometric evaluations. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The Rating Schedule provides rating tables for the evaluation of hearing impairment. Table VI assigns a Roman numeral designation (I through XI) for hearing impairment based on a combination of percent speech discrimination and the puretone threshold average (the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four). 38 C.F.R. § 4.85. Table VIA will be used when the examiner certifies that use of the speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of 38 C.F.R. § 4.86. Id. Table VII is used to determine the percentage evaluation by combining the Table VI or Table VIA Roman numeral designations for hearing impairment in each ear. Id. 38 C.F.R. § 4.86 provides for exceptional patterns of hearing impairment. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. 38 C.F.R. § 4.86(a). Each ear is evaluated separately. Id. When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation from either Table VI or Table VIA, whichever results in the higher numeral. 38 C.F.R. § 4.86(b). That numeral is then elevated to the next higher Roman numeral. Id. In this case, a February 2015 VA examination report reflects review of the Veteran’s claims file, and a diagnosis of bilateral sensorineural hearing loss. Puretone testing results, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 25 45 65 70 51 LEFT 25 55 70 70 55 Speech recognition ability based on the Maryland CNC word list was 76 percent in the right ear, and 72 percent in the left ear. The Veteran complained of difficulty hearing in conversations. The examination results for the right ear, applied to Table VI, yield a numeric designation of IV in the right ear on the basis of 51 decibel puretone threshold average and 76 percent speech discrimination. The examination results for the left ear, applied to Table VI, yield a numeric designation of V in the left ear on the basis of 55 decibel puretone threshold average and 72 percent speech discrimination. When the numeric designation of IV is entered for the right ear into Table VII along with the numeric designation of V for the left ear, an evaluation of 10 percent for hearing impairment is produced. In Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007), the Court held that, relevant to VA audiological examinations, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. The Court also noted, however, that even if an audiologist’s description of the functional effects of the Veteran’s hearing disability was somehow defective, the Veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. In this case, the VA examiner addressed functional effects of hearing loss by noting that the Veteran had difficulty hearing in conversations. Therefore, the functional effects of his hearing loss disability are adequately addressed in the record. The Board acknowledges statements by the Veteran regarding his inability to hear and contentions that higher ratings are warranted. In terms of competency, lay evidence has been found to be competent with regard to a disease with “unique and readily identifiable features” that is “capable of lay observation.” See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). In this case, lay persons are not competent to provide evidence as to more complex medical questions and, specifically, are not competent to provide objective evidence measuring the degree of hearing loss. The Board reiterates that hearing impairment disability ratings are assigned by a mechanical application of audiological testing results to the tables provided by the applicable regulations, as described and applied in the analysis above. See 38 C.F.R. §§ 4.85, 4.86. The Board does not doubt that the Veteran’s hearing impairment results in the difficulties described; however, such descriptions, alone, do not convert to higher disability ratings. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to service connection for low back pain is remanded. The claim for service connection for low back pain is remanded for a VA examination. The Veteran reported that he currently continued to have back pain and still received treatment for such. Additionally, the Veteran stated that he was in a motor vehicle accident in 1991 while stationed in Kuwait, where his vehicle landed in a ditch after being hit from behind by another vehicle. The Board acknowledges that a September 2015 private evaluation report documents an opinion that the Veteran’s low back disorder was at least as likely as not related to active service. As rationale, the private doctor stated that the Veteran complained of back pain in June 1967, that back pain continued to the present, and that there was no other evidence to suggest any alternative etiology. Unfortunately, this opinion is not adequate as the evidence demonstrates the Veteran’s denials of back pain subsequent to the June 1967 complaint of low back pain. The Veteran has not yet been afforded a VA examination to determine whether his claimed current low back pain is related to service. See 38 C.F.R. § 3.159(c)(4). This should be completed on remand. 2. Entitlement to service connection for OSA is remanded. The claim for service connection for OSA is remanded for a new VA examination. The Board acknowledges that the Veteran was diagnosed with OSA by a December 2014 sleep study. He was provided a VA examination in February 2015, at which time the VA examiner opined that the Veteran’s OSA was likely due to his obesity, noting that medical literature did not support an etiologic link between OSA and exposure to fumes, dust, and smoke. She also reported that the Veteran had submitted evidence claiming that he snored during service and since 1991, but stated that there was no proof without speculation that the alleged in-service snoring was due to OSA. Subsequently, the Veteran submitted a lay statement reflecting in-service symptoms, such as waking up with headaches, feeling sleepy, and snoring loudly and having shortness of breath while sleeping. Additionally, the Veteran submitted a private September 2015 evaluation report reflecting a positive opinion. Unfortunately, the private doctor’s only rationale was that there was no other evidence suggesting any alternative etiology. The Board finds that a new VA examination is required in order to address all of the subsequently submitted evidence. 3. Entitlement to service connection for migraines is remanded. The February 2015 VA examiner opined that the Veteran’s migraines were more likely due to stress or related to his OSA. As such, the Veteran’s claim for service connection for migraines is inextricably intertwined with the claim for service connection for OSA remanded herein, and the adjudication of this claim depends on the outcome of the remanded OSA claim. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). 4. Entitlement to service connection for a right side ulcer with pain is remanded. The claim for service connection for a right side ulcer with pain is remanded for a VA examination. In October 2008, the Veteran was diagnosed with a benign liver tumor and abdominal pain. STRs reflect that the Veteran complained of pain on the right side in December 1990. The Veteran has not yet been afforded a VA examination to determine whether his liver benign tumor and abdominal pain are related to service. See 38 C.F.R. § 3.159(c)(4). This should be completed on remand. 5. Entitlement to service connection for a psychiatric disorder, to include PTSD and an unspecified depressive disorder, is remanded. The claim for service connection for a psychiatric disorder is remanded for a new VA examination. At his February 2015 VA examination, the examiner found that the Veteran did not meet the diagnostic criteria for PTSD, but did meet the criteria for a diagnosis of unspecified depressive disorder, which he opined was less likely than not incurred in or caused by active service. Subsequently, a private September 2015 evaluation report reflects that the Veteran now met the diagnostic criteria for PTSD and major depressive disorder, and a positive opinion that the Veteran’s depression was in direct relation to service. However, no rationale was provided other than that there was no other evidence suggesting any alternative etiology. As such, the opinion is inadequate. Additionally, the Veteran contended that his psychiatric disorders may be secondary to his service-connected disabilities. Moreover, an August 2016 letter from a private psychiatrist suggests that the Veteran’s psychiatric symptoms may be related to his in-service combat. Given the new evidence, a new VA examination is required. Furthermore, the RO should attempt to corroborate the Veteran’s claimed stressors, to include attack on his compound in Kuwait in February 1991 and attack in April 1991 while escorting a bus full of prisoners of war. 6. Entitlement to service connection for claustrophobia is remanded. The claim for service connection for claustrophobia is remanded for a VA examination. The Veteran stated that his current claustrophobia was the result of an incident in Kuwait when he was left inside of a tank. Additionally, he described an incident where he was stuck in an elevator for at least 20 minutes at the airport before going to the Persian Gulf. The Veteran has not yet been afforded a VA examination to determine whether he has an actual diagnosis of claustrophobia that is related to service. See 38 C.F.R. § 3.159(c)(4). 7. Entitlement to service connection for a right knee disorder is remanded. The claim for service connection for a right knee disorder is remanded for a new VA examination. In his February and August 2016 VA Forms 9, the Veteran contended that his right knee disorder was secondary to his service-connected left knee disability. Although the Veteran was provided a VA examination in October 2015, the examiner did not address secondary service connection. 8. Entitlement to an initial rating in excess of 10 percent for a left knee disability is remanded. The claim for a higher rating for a left knee disability is remanded for a new VA examination. The Veteran last had a VA examination to evaluate his left knee disability in October 2015, where he had flexion to 100 degrees and no ankylosis. However, in his February and August 2016 VA Forms 9, he contended that he now had ankylosis due to extremely unfavorable flexion limited to 45 degrees or more. Given the indication of a possible worsening, a new examination is necessary. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). 9. Entitlement to a TDIU is remanded. The Veteran’s claim for a TDIU is inextricably intertwined with the claims remanded herein, and the adjudication of this claim may depend on the outcome of the other remanded claims. See Parker, supra. The matters are REMANDED for the following action: 1. Prepare a list of the Veteran’s claimed stressors and attempt to verify them by contacting the appropriate agencies. He has asserted the following stressors: a) When his compound in Kuwait was constantly receiving enemy fire, mortars, artillery, RPGs, and incoming fire scout missiles at night in February 1991; b) He was escorting a bus full of prisoners of war when they were confronted with enemy small-arm fire, which resulted in one of the prisoners dying in or around April 1991; c) Active combat while deployed to Kuwait in 1990 to 1991, where helicopters surrounded the plane he was on to provide support and when another vehicle hit the vehicle he was in while in a convoy; and d) When he witnessed an Iraqi prisoner cut his throat. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with regard to requesting records from Federal facilities. If any additional stressor details are needed from the Veteran, provide a detailed explanation as to what details are needed, and request them from him. 2. Provide a comprehensive VA examination by an appropriate examiner to determine the nature and etiology of the Veteran’s claimed low back pain. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. Although a complete review of the record is imperative, attention is called to the following: *A June 1967 STR reflecting a complaint of low back pain. * February 2015 and June 2015 statements in which the Veteran reported a motor vehicle accident in 1991 when he was stationed in Kuwait, where his vehicle landed in a ditch after being hit from behind by another vehicle. *The private September 2015 evaluation report with a positive opinion. After reviewing the claims file in its entirety and examining the Veteran, the examiner is asked to address the following: a) Identify all diagnoses involving the Veteran’s low back, resulting in his claimed low back pain. b) Provide an opinion as to whether the Veteran’s low back disorder at least as likely as not had its onset during active service or is otherwise related to it. **In doing so, the VA examiner should consider all evidence, to include the June 1967 STR and the Veteran’s contentions of a motor vehicle accident in 1991.** **The VA examiner should also address the private September 2015 evaluation report and the opinion and findings provided.** A complete rationale should be provided for any opinion provided. 3. Provide a comprehensive VA examination by an appropriate examiner to determine the nature and etiology of the Veteran’s OSA. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. Although a complete review of the record is imperative, attention is called to the following: *A December 2014 sleep studying resulting in a diagnosis of OSA. *The February 2015 VA examination report. *A March 2015 lay statement from J.M.P. *A June 2015 NOD in which the Veteran contended that his OSA was due to breathing contaminated air in the Persian Gulf, which caused shortness of breath at night, loud snoring, difficulty falling asleep, difficulty with memory, and feeling sleepy in the morning. *The private September 2015 evaluation report reflecting a positive opinion. After reviewing the claims file in its entirety and examining the Veteran, the examiner is asked to address the following: Whether the Veteran’s OSA at least as likely as not had an onset during active service or are otherwise related to it, to include his in-service symptoms or exposure to environmental hazards in the Persian Gulf. A complete rationale should be provided for any opinion provided. 4. Provide a comprehensive VA examination by an appropriate examiner to determine the nature and etiology of the Veteran’s claimed right side ulcer with pain. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. Although a complete review of the record is imperative, attention is called to the following: *A December 1990 STR reflecting pain on the right side. *The October 2008 private treatment record reflecting diagnoses of benign liver tumor and abdominal pain. After reviewing the claims file in its entirety and examining the Veteran, the examiner is asked to address the following: Whether the Veteran’s current diagnoses of benign liver tumor and abdominal pain are at least as likely as not had their onset during active service or are otherwise related to it, to include the in-service complaint of pain on the right side and exposure to environmental hazards in the Persian Gulf. A complete rationale should be provided for any opinion provided. 5. Provide a comprehensive VA examination by an appropriate examiner to determine the nature and etiology of the Veteran’s psychiatric disorder. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. Although a complete review of the record is imperative, attention is called to the following: *A November 2014 statement reflecting the Veteran’s report of stressors occurring in February 1991 and April 1991. *The February 2015 VA examination report. *A February 2015 statement in which the Veteran discussed in-service stressors. *A March 2015 statement in which the Veteran contended that his psychiatric disorder may be secondary to his service-connected disabilities. *A March 2015 statement from the Veteran’s wife in which she discussed his symptoms, which began upon returning home from Operation Desert Shield/Desert Storm. *A September 2015 VA Form 9 in which the Veteran contended that his unspecified depressive disorder was related to his service-connected bilateral hearing loss. *A private September 2015 evaluation report reflecting diagnoses of major depressive disorder and PTSD. *An August 2016 letter from a private psychiatrist. *A December 2017 statement in which the Veteran contended that his PTSD “took [some time] to fully develop” and that he was first treated for PTSD in 1996. After reviewing the claims file in its entirety and examining the Veteran, the examiner is asked to address the following: a) Determine whether the Veteran meets the criteria for a diagnosis of PTSD based on DSM-5. If the examiner determines that the Veteran does not have PTSD, he or she should address the PTSD diagnosis reflected in the record and discuss whether the new diagnosis represents progression of the prior diagnosis, correction of an error in the prior diagnosis, or development of a new and separate condition. 38 C.F.R § 4.125(b). b) If PTSD is currently demonstrated, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s PTSD had an onset during the Veteran’s active service or was caused by his active service, to include his claimed stressors. The examiner should identify the specific stressor(s) underlying the diagnosis, and should comment upon the link between the current symptomatology and the Veteran’s claimed stressor(s). In so doing, the examiner should determine whether the claimed stressor(s) has been verified. c) For any other diagnosed psychiatric disorder, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the such other diagnosed psychiatric disorder, to include unspecified depressive disorder, began in or is the result of military service. d) For each psychiatric disorder, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that such psychiatric disorder is caused by, aggravated by, or related to the Veteran’s service-connected disabilities. He is currently service-connected for bilateral hearing loss and a left knee disability. A complete rationale should be provided for any opinion provided. 6. Provide a comprehensive VA examination by an appropriate examiner to determine the nature and etiology of the Veteran’s claimed claustrophobia. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. Although a complete review of the record is imperative, attention is called to the following: *A June 2015 statement in which the Veteran described an incident where he was stuck in an elevator at the airport for at least 20 minutes before boarding a plane to the Persian Gulf. *The September 2015 VA Form 9 in which the Veteran contended that his claustrophobia was the result of being left inside of a tank while stationed in Kuwait. After reviewing the claims file in its entirety and examining the Veteran, the examiner is asked to address the following: a) Confirm whether the Veteran has an actual diagnosis of claustrophobia. b) Provide an opinion as to whether the Veteran’s claustrophobia at least as likely as not had its onset during active service or is otherwise related to it. **In doing so, the VA examiner should consider all evidence, to include the Veteran’s reports of being stuck in an elevator and being left inside of a tank.** A complete rationale should be provided for any opinion provided. 7. Provide a comprehensive VA examination by an appropriate examiner to determine the nature and etiology of the Veteran’s claimed right knee disorder and the current severity of his service-connected left knee disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. Although a complete review of the record is imperative, attention is called to the following: *A December 1990 STR reflecting the Veteran’s complaint of right knee pain and order to have no physical training for three days and no running for six days. *A December 1991 examination report reflecting trauma to the right knee. *The October 2015 VA examination report. *The Veteran’s February and August 2016 VA Forms 9 in which he contended that his right knee disorder was secondary to his service-connected left knee disability. After reviewing the claims file in its entirety and examining the Veteran, the examiner is asked to address the following: a) Provide an opinion as to whether the Veteran’s claimed right knee disorder at least as likely as not had its onset during active service or is otherwise related to it. **In doing so, the VA examiner should consider all evidence, to include the December 1990 STR.** b) Provide an opinion as to whether the Veteran’s claimed right knee disorder is caused by, aggravated by, or is otherwise related to his service-connected right knee disability. c) Indicate all current symptoms associated with the Veteran’s service-connected left knee disability and address their severity. d) Test and report the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing for the joint in question AND any paired joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, s/he should clearly explain why that is so. If an opinion cannot be given without resorting to mere speculation, the VA examiner should state so and further provide a reason for such conclusion. e) In reporting the range-of-motion findings, comment on the extent of any painful motion, at which measurement the pain begins, functional loss due to pain, weakness, excess fatigability, and additional disability during flare-ups or upon repetitive use testing. f) Provide information concerning the functional impairment resulting from the service-connected left knee disability that may impact the Veteran’s ability to function and perform tasks in a work or work-like setting. A complete rationale should be provided for any opinion provided. (Continued on the next page)   8. Thereafter, readjudicate the Veteran’s claims on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jane R. Lee