Citation Nr: 18147493 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 15-23 354A DATE: November 5, 2018 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for depression is granted. Entitlement to a rating in excess of 20 percent for status post left clavicle fracture is denied. Entitlement to an initial rating in excess of 10 percent for cervical intervertebral disc syndrome with arthritis is denied. Prior to February 27, 2015, entitlement to an initial rating in excess of 10 percent for lumbar osteoarthritis is denied. From February 27, 2015, entitlement to an initial rating of 20 percent for lumbar osteoarthritis is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to an initial rating in excess of 10 percent for left knee strain is denied. Entitlement to an initial rating in excess of 10 percent for right knee strain is denied. Entitlement to a separate rating of 10 percent for left knee lateral instability is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to a separate 10 percent rating for right knee lateral instability is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to a rating of 30 percent for gastrointestinal reflex disease (GERD) is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to an initial rating in excess of 10 percent for left upper extremity radiculopathy is denied. Entitlement to an effective date earlier than February 13, 2012 for the grant of service connection for cervical intervertebral disc syndrome with arthritis is denied. Entitlement to an effective date earlier than February 13, 2012 for the grant of service connection for left upper extremity radiculopathy is denied. Entitlement to an effective date earlier than September 30, 2011 for the grant of service connection for lumbar osteoarthritis is denied. Entitlement to an effective date earlier than September 30, 2011 for the grant of service connection for left knee strain is denied. Entitlement to an effective date earlier than September 30, 2011 for the grant of right knee strain is denied. Entitlement to an effective date earlier than February 13, 2012 for the award of 20 percent for status post left clavicle fracture is denied. REMANDED Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for a sleep disorder, to include insomnia and sleep apnea, is remanded. Entitlement to service connection for a left shoulder disability (other than status post left clavicle fracture) is remanded. Entitlement to a total rating for disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran does not have a hearing loss disability as defined by VA regulation. 2. Depression is likely caused by the Veteran’s service-connected disabilities. 3. The Veteran’s status post left clavicle fracture is manifested by pain, but not limitation of motion to a point midway between the side and shoulder level. 4. The Veteran’s cervical spine disability is manifested by pain and limitation of motion; forward flexion of the cervical spine to 30 degrees or less, a combined cervical spine range of motion of 170 degrees or less, muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour, and incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months are not shown. 5. Prior to February 27, 2015, the Veteran’s lumbar spine disability was manifested by pain and limitation of motion; flexion limited to 60 degrees or less and muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour are not shown. 6. From February 27, 2015, the Veteran’s lumbar spine disability is manifested by flexion limited to 60 degrees at worst (with consideration of pain). 7. The Veteran’s left knee disability is manifested by pain, limitation of flexion to no worse than 65 degrees, normal extension, and occasional swelling; subluxation, dislocation of semilunar cartilage, genu recurvatum, impairment of the tibia or fibula, or ankylosis are not shown. 8. The Veteran’s right knee disability is manifested by pain, limitation of flexion to no worse than 75 degrees, normal extension, and occasional swelling; subluxation, dislocation of semilunar cartilage, genu recurvatum, impairment of the tibia or fibula, or ankylosis are not shown. 9. The evidence is at least evenly balanced as to whether symptoms of the Veteran’s right and left knee disability have more nearly approximated slight lateral instability, but the preponderance of the evidence reflects that they have not more nearly approximated moderate lateral instability. 10. The Veteran’s GERD causes occasional vomiting, dysphagia, regurgitation, reflux, heartburn, substernal arm or shoulder pain, and anemia, some of which are controlled, at least in part, by medication, productive of considerable impairment of health. 11. The Veteran’s left upper extremity radiculopathy is not manifested by moderate incomplete paralysis of the ulnar nerve. 12. A November 1997 rating decision denied service connection for knee and low back disabilities; the Veteran did not appeal that decision or submit new and material evidence. 13. The Veteran’s petition to reopen a service connection claim for knee and low back disabilities was received on September 30, 2011. 14. The Veteran’s claim of entitlement to service connection for a cervical spine disability and left upper extremity radiculopathy was received by VA on February 13, 2012. 15. A claim for an increased rating for service-connected status post left clavicle fracture was received on February 13, 2012; it is not factually ascertainable that the increase in severity warranting a higher rating occurred during the one year prior to that date. CONCLUSIONS OF LAW 1. The criteria for service connection for hearing loss are not met. 38 U.S.C. §§ 1110, 5107 (2014); 38 C.F.R. §§ 3.159, 3.303, 3.385 (2017). 2. With resolution of reasonable doubt in the Veteran’s favor, the criteria for service connection for depression are met. 38 U.S.C. §§ 1110, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 3. The criteria for a rating in excess of 20 percent for status post left clavicle fracture have not been met. 38 U.S.C. § 1155, 5107 (2014); 38 C.F.R. §§ 3.321, 4.1 – 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5201 (2017). 4. The criteria for an initial rating in excess of 10 percent for cervical intervertebral disc syndrome with arthritis have not been met. 38 U.S.C. § 1155, 5107 (2014); 38 C.F.R. §§ 3.321, 4.1 – 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5242-5237 (2017). 5. The criteria for an initial rating in excess of 10 percent for lumbar osteoarthritis, prior to February 27, 2015, have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.321, 4.1 - 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242 (2017). 6. With resolution or reasonable doubt in the Veteran’s favor, the criteria for an initial evaluation of 20 percent, but no higher, for lumbar osteoarthritis have been met as of February 27, 2015. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.321, 4.1 - 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242 (2017). 7. The criteria for an initial rating in excess of 10 percent for left knee strain have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.321, 4.1 - 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260 (2017). 8. The criteria an initial rating in excess of 10 percent for right knee strain have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.321, 4.1 - 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260 (2017). 9. With reasonable doubt resolved in favor of the Veteran, the criteria for a separate 10 percent rating, but no higher, for left knee lateral instability are met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.102, 3.321, 4.1 - 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5257 (2017). 10. With reasonable doubt resolved in favor of the Veteran, the criteria for a separate 10 percent rating, but no higher, for left knee lateral instability are met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.102, 3.321, 4.1 - 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5257 (2017). 11. With resolution of reasonable doubt in the Veteran’s favor, the criteria for a 30 percent rating, but no higher, for GERD have been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.102, 3.321, 4.1 - 4.7, 4.114, DC 7346 (2017). 12. The criteria for an initial rating in excess of 10 percent for left upper extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.321, 4.1 - 4.7, 4.124a, DC 8616 (2017). 13. The criteria for an effective date earlier than February 13, 2012 for the grant of service connection for cervical intervertebral disc syndrome with arthritis have not been met. 38 U.S.C. § 5110 (2014); 38 C.F.R. § 3.400 (2017). 14. The criteria for an effective date earlier than February 13, 2012 for the grant of service connection for left upper extremity radiculopathy have not been met. 38 U.S.C. § 5110 (2014); 38 C.F.R. § 3.400 (2017). 15. The criteria for an effective date earlier than September 30, 2011 for the grant of service connection for lumbar osteoarthritis have not been met. 38 U.S.C. § 5110 (2014); 38 C.F.R. § 3.400 (2017). 16. The criteria for an effective date earlier than September 30, 2011 for the grant of service connection for left knee strain have not been met. 38 U.S.C. § 5110 (2014); 38 C.F.R. § 3.400 (2017). 17. The criteria for an effective date earlier than September 30, 2011 for right knee strain have not been met. 38 U.S.C. § 5110 (2014); 38 C.F.R. § 3.400 (2017). 18. The criteria for an effective date earlier than February 13, 2012 for the award of 20 percent for status post left clavicle fracture have not been met. 38 U.S.C. § 5110 (2014); 38 C.F.R. § 3.400 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1990 to September 1997. The sleep apnea claim has been recharacterized to accurately reflect the Veteran’s contentions and the medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). To the extent that the Veteran’s December 2013 Notice of Disagreement (NOD) may be read as an appeal for an earlier effective date for the grant of service connection for GERD, the Board notes that it was not timely with respect to the November 1997 rating decision that granted service connection. Thus, any attempt to raise that issue now is a freestanding claim for an effective date and not contemplated under the law. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). A Statement of the Case (SOC) has not been filed for entitlement to service connection for a left shoulder disability (other than status post left clavicle fracture). Thus, the Board must remand this issue for an SOC. See 38 C.F.R. § 19.9 (c); Manlincon v. West, 12 Vet. App. 238 (1999). In April 2018, the RO granted service connection for right lower extremity radiculopathy (10 percent, effective August 8, 2013). The Veteran filed a Notice of Disagreement (NOD) in October 2018 with respect to both the rating and effective date. It appears that the RO is actively working on that appeal. Thus, the Board declines taking jurisdiction over that issue. Service Connection Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303 (a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For specific enumerated diseases designated as “chronic” there is a presumption that such chronic disease was incurred in or aggravated by service even though there is no evidence of such chronic disease during the period of service. In order for the presumption to attach, the disease must have become manifest to a degree of 10 percent or more within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). Presumptive service connection for the specified chronic diseases may alternatively be established by way of continuity of symptomatology under 38 C.F.R. § 3.303 (b). However, the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 1. Entitlement to service connection for bilateral hearing loss For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran’s MOS was infantryman. An April 1988 audiogram indicates that he was routinely exposed to hazardous noise. Thus, noise exposure during service is conceded. Service treatment records (STRs) show normal ears during the March 1990 enlistment examination. Audiometric findings in the right ear were recorded as follows: 5 decibels (dB) at 500 Hertz (Hz), 0 dB at 1000 Hz, 0 dB at 2000 Hz, and 5 dB at 3000 Hz, and 10 dB at 4000 Hz. Audiometric findings in the left ear were recorded as follows: 5 decibels (dB) at 500 Hertz (Hz), 0 dB at 1000 Hz, 0 dB at 2000 Hz, and 5 dB at 3000 Hz, and 5 dB at 4000 Hz. A January 1992 audiogram contains the following audiometric findings in the right ear: 5 decibels (dB) at 500 Hertz (Hz), 5 dB at 1000 Hz, 5 dB at 2000 Hz, 0 dB at 3000 Hz, and 15 dB at 4000 Hz. Audiometric findings in the left ear were recorded as follows: 5 decibels (dB) at 500 Hertz (Hz), 5 dB at 1000 Hz, 0 dB at 2000 Hz, and 5 dB at 3000 Hz, and 5 dB at 4000 Hz. A January 1993 audiogram contains the following audiometric findings in the right ear: 5 decibels (dB) at 500 Hertz (Hz), 5 dB at 1000 Hz, 5 dB at 2000 Hz, 0 dB at 3000 Hz, and 15 dB at 4000 Hz. Audiometric findings in the left ear were recorded as follows: 5 decibels (dB) at 500 Hertz (Hz), 5 dB at 1000 Hz, 0 dB at 2000 Hz, and 5 dB at 3000 Hz, and 5 dB at 4000 Hz. A January 1994 audiogram contains the following audiometric findings in the right ear: 10 decibels (dB) at 500 Hertz (Hz), 5 dB at 1000 Hz, 5 dB at 2000 Hz, 0 dB at 3000 Hz, and 10 dB at 4000 Hz. Audiometric findings in the left ear were recorded as follows: 10 decibels (dB) at 500 Hertz (Hz), 0 dB at 1000 Hz, 0 dB at 2000 Hz, and 0 dB at 3000 Hz, and 10 dB at 4000 Hz. A corresponding treatment note shows that the Veteran denied any hearing loss and reportedly wore hearing protection. It was noted his MOS exposed him to hazardous noise. In May 1996, it was noted that the Veteran had wax build up in both ears. He denied any hearing loss at that time. The Veteran submitted to an August 2013 VA hearing loss examination. Audiometric findings for the right ear were recorded as follows: 20 decibels (dB) at 500 Hertz (Hz), 20 dB at 1000 Hz, 15 dB at 2000 Hz, 10 dB at 3000 Hz, and 20 dB at 4000 Hz. Audiometric findings for the left ear were recorded as follows: 30 decibels (dB) at 500 Hertz (Hz), 20 dB at 1000 Hz, 20 dB at 2000 Hz, 20 dB at 3000 Hz, and 25 dB at 4000 Hz. Speech recognition ability was 96 percent in the right ear and 94 percent in the left ear. The examiner diagnosed normal hearing in the both ears. The Veteran does not have auditory thresholds of 26 decibels for at least three of the required frequencies, he does not have a threshold of 40 decibels for any of the required frequencies, and his speech recognition is at least 94 percent. Accordingly, service connection for bilateral hearing loss must be denied based on lack of current disability. See 38 C.F.R. § 3.385. 2. Entitlement to service connection for depression In July 2018, the Veteran’s attorney submitted an April 2016 Disability Benefits Questionnaire from a private doctor, who opined that the Veteran’s various service-connected disabilities “are more likely than not causing his depressive disorder.” The doctor reviewed the Veteran’s subjective history, claims file and clinical findings, and rendered an opinion with supportive rationale and medical journal articles. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board considers this private opinion adequate. There is no evidence to the contrary. Thus, service connection for depression is warranted. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during active military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). In both initial rating claims and normal increased rating claims, the Board must discuss whether “staged ratings” are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, a higher rating must be considered where the evidence demonstrates additional functional loss due to pain, pursuant to 38 C.F.R. §§ 4.40 and 4.45. This includes greater limitation of motion due to pain on use, including use during flare-ups. DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board notes that the VA examination reports do not include passive range of motion and do not specify range of motion without weight bearing. Generally, active range of motion testing produces more restrictive results than passive range of motion testing, in that passive range of motion testing requires the physician to force the joint through its motions. There is no indication that the range of motion testing in these examinations was performed other than on weight-bearing. Therefore, there is no prejudice to the Veteran in relying on these VA examinations that involved active range of motion testing because such results tend to produce the “worst case scenario” of impairment and thus would tend to support the highest possible rating. The Board has carefully considered the Veteran’s assertions regarding the severity of his service-connected disabilities. He is competent to state how he experiences symptoms, such as pain, that require only personal knowledge as it comes to him through his senses. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, he is not competent to identify the specific level of disability according to the relevant diagnostic codes. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 3. Entitlement to a rating in excess of 20 percent for status post left clavicle fracture The evidence shows that the Veteran is right handed. Thus, the ratings assigned for limitation of motion of the minor upper extremity in DC 5201 apply. See 38 C.F.R. § 4.69. Under Diagnostic Code 5201, a rating of 20 percent is warranted when motion of the minor arm is limited to shoulder level. A 20 percent rating is also warranted for limitation of motion of the minor arm midway between the side and shoulder level. A 30 percent rating is warranted where motion of the minor arm is limited to 25 degrees from the side. See 38 C.F.R. § 4.71a, DC 5201. Limitation of motion under DC 5201 may be compensated based on limitation of abduction or limitation of flexion - the two planes of movement involving lifting the arm from the side - whichever would afford the higher rating. Yonek v. Shinseki, 722 F.3d, 1355, 1358 - 59 (2013) (citing Mariano v. Principi, 17 Vet. App. 305, 314 - 16 (2003)). However, separate ratings for both limitation of abduction and flexion are not available. Id. A rating of 20 percent or higher under DC 5201 requires limitation of motion at shoulder level or less, which is essentially 90 degrees or less. See 38 C.F.R. § 4.71, Plate I. There is no lay or medical evidence showing that the left arm was limited to midway between the side and shoulder level, or to 25 degrees from side. Thus, a rating greater than 20 percent is not warranted. The Board recognizes the Veteran’s complaints of functional loss, notably his pain and inability to sleep on his left side. An October 2017 VA treatment record shows that he complained of a sharp pain when reaching and a radiating pain that affected dressing, bathing, lifting, and cleaning. However, September 2017 VA treatment records show the Veteran was still able to demonstrate range of motion that greatly exceeded 25 degrees from the side. The Board has also considered whether other Diagnostic Codes pertaining to impairment of the shoulder and arm are applicable. There is no evidence of any impairment or malunion of the humerus as required for a rating in excess of 20 percent under DC 5202. The Veteran’s left shoulder is obviously not ankylosed as required for a higher rating under DC 5200. Nor has the Veteran been diagnosed with arthritis of the left shoulder. With regard to a separate rating under DC 5203, the Board acknowledges that the January 2013 VA examiner found malunion of the clavicle. However, the highest possible evaluation under 5203 is 10 percent. In addition, a separate evaluation under DC 5203 is inappropriate because it would twice compensate the Veteran for the pain that he experiences in his left shoulder. In other words, assigning the Veteran a separate rating under DC 5203 would constitute impermissible pyramiding and is therefore inappropriate. The Board has also considered whether the schedular evaluation is inadequate. The evidence does not reflect any unusual or otherwise exceptional symptoms. The primary symptoms of pain and limited motion are fully contemplated by the rating criteria. 4. Entitlement to an initial rating in excess of 10 percent for cervical intervertebral disc syndrome with arthritis Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (DCs 5235 to 5243). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Under the General Rating Formula, a 10 percent disability rating is assigned for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, General Rating Formula. A 20 percent disability rating is assigned for forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 30 percent disability rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent disability rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is assigned if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. When a veteran has intervertebral disc syndrome (IVDS), ratings can also be assigned based on the duration of incapacitating episodes (acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician). 38 C.F.R. § 4.71a, DC 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Separate ratings cannot be assigned based on the General Formula and the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. See id. Based on a review of the evidence, the Board concludes that a schedular rating in excess of 10 is not warranted. The evidence does not suggest guarding or muscle spasm severe enough to result in an abnormal gait or abnormal spinal contour. Range of motion testing performed during the VA examinations showed at worst forward flexion of the cervical spine to 40 degrees and a combined range of cervical motion well in excess of the 170 degrees required for a 20 percent rating. There is no competent medical evidence of record to the contrary in the record. The Board accepts that the Veteran has limitation of motion of the cervical spine and chronic neck pain. With respect to functional limitation, the Veteran contends that it takes him longer to put his shoes and socks on and that he has limited rotation, especially when driving or standing on a ladder. He has reported flare-ups every three weeks. See January 2013 and February 2015 VA examinations. However, neither the lay nor medical evidence reflects the functional equivalent of limitation of flexion required for a 20 percent rating. The lay and medical evidence demonstrates that the currently assigned 10 percent rating is appropriate for the Veteran’s neck disability. In addition, the evidence does not reflect any associated neurological findings during the appeal period other than the service-connected left upper extremity radiculopathy. See February 2015 VA Peripheral Nerves Examination. Thus, any other separate rating based on associated neurological abnormalities is not warranted at any time during the appeal period. Finally, a rating based on IVDS is not warranted. Although the Veteran has been diagnosed with IVDS, he did not report, and the evidence does not show, any incapacitating episodes during the appeal period. Accordingly, there is no evidence of incapacitating episodes having a total duration of least 2 weeks, but less than 4 weeks, which would result in higher rating. The Board has also considered whether the schedular evaluation is inadequate. The evidence does not reflect any unusual or otherwise exceptional symptoms. The primary symptoms of pain and limited motion are contemplated by the schedular rating criteria. 5. Entitlement to an initial rating in excess of 10 percent for lumbar osteoarthritis Under the General Rating Formula, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; 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 at 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 rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Because the evidence shows no IVDS for the entire initial rating period on appeal, the Board finds that the back disability is appropriately rated under the General Rating Formula. See January 2013 and February 2015 VA Examination Reports (noting that the Veteran does not have IVDS of the thoracolumbar spine). Throughout the appeal period, the Veteran’s back disability was not manifested by a combined range of motion of the thoracolumbar spine of 120 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or flexion greater than 30 but not worse than 60 as required for a higher disability rating of 20 percent under the General Rating Formula. The Veteran has been diagnosed with scoliosis, but it is congenital. See January 2013 VA Examination. The Board has considered whether the Veteran’s back disability results in functional loss. It is not disputed that the Veteran has limitation of motion of the lumbar spine and chronic back pain. The January 2013 VA examination report reflects flexion to 80 degrees with no pain. The examiner found increased pain and less movement after repetitive use testing, but no additional loss of motion. He did not assess for functional loss during flare-ups although the Veteran noted that his back could “give way” without warning and that aching severely limited his movement for days. VA treatment records are absent findings of a loss of range of motion on any flare-ups. The evidence thus reflects that the limitations caused by the DeLuca/Mitchell factors prior to February 27, 2015 do not cause the orthopedic symptoms of the Veteran’s back disability to more nearly approximate forward flexion of the thoracolumbar spine to 60 degrees or less, or a combined range of motion of the thoracolumbar spine of 120 degrees or less. However, the medical evidence supports a finding that the Veteran has had functional loss in his lumbar spine since February 27, 2015. The February 2015 VA examination report reflects flexion to 65 degrees with no pain. The February 2015 VA examiner declined to assess for functional loss after repetitive testing and during flare-ups since the examination did not take place under those circumstances. However, the Veteran has adequately described the severity, frequency, and duration of his flare-ups and their functional impact. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). He and his wife have reported during this time period that his back is worse with bending, lifting, and prolonged standing/walking. He told the February 2015 VA examiner that he is unable to put his shoes on, among other activities. Therefore, a 20 percent rating under DC 5242 from February 27, 2015 is warranted for functional loss due to pain. The evidence of record does not reflect any associated neurological findings other than the service-connected right lower extremity radiculopathy. The February 2015 VA examiner specifically found no radiculopathy of the left lower extremity. No bowel or bladder dysfunction has been shown to be associated with the Veteran’s service-connected low back disability. Indeed, on evaluation, the Veteran himself has denied any bowel or bladder problems. Thus, a separate rating based on associated neurological abnormalities is not warranted at any time during the appeal period. The Board has also considered whether the schedular evaluation is inadequate. The clinical examiners, including most recently in February 2015, have not identified any unusual or otherwise exceptional symptoms. The primary symptoms of pain and limited motion are contemplated by the schedular rating criteria. Review of VA treatment records dated from January 2013 to December 2015 do not identify any extraordinary symptoms. Although limitation of activities, such as walking, and use of a brace are not specifically noted in the rating schedule, it is clear the Veteran’s activities are limited due to his back pain and decreased motion, all of which are accounted for by the rating schedule. See Spellers v. Wilkie, 2018 U.S. App. Vet (September 7, 2018) (holding that the symptoms of sciatica that caused the veteran to use assistive devices are contemplated by the schedular rating criteria). 6. Entitlement to an initial rating in excess of 10 percent for left knee strain 7. Entitlement to an initial rating in excess of 10 percent for right knee strain 8. Entitlement to a separate compensable rating for left knee lateral instability. 9. Entitlement to a separate compensable rating for right knee lateral instability. DC 5260 addresses limitation of flexion of the leg. Flexion limited to 60 degrees warrants a noncompensable rating. Flexion limited to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, DC 5260. DC 5261 addresses limitation of extension of the leg. Extension limited to 10 degrees warrants a 10 percent rating. Extension limited to 5 degrees warrants a noncompensable rating. Extension limited to 15 degrees warrants a 20 percent rating. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, DC 5261. Separate ratings may be assigned under DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg). VAOPGCPREC 9-2004. Lateral instability and limitation of motion of the knee may be rated separately under DCs 5257 and 5003. VAOPGCPREC 23-97. Under DC 5257, a 10 percent evaluation is assigned for slight recurrent subluxation or lateral instability. A 20 percent rating is assigned for moderate recurrent subluxation or lateral instability. A 30 percent disability rating is assigned under for severe recurrent subluxation or lateral instability. Based on a review of the evidence, the Board has determined that the Veteran is not entitled to a compensable rating under DC 5261 or DC 5260. Extension has consistently been zero degrees. See January 2013 and February 2015 VA Examination Reports. Flexion has been limited to no worse than 75 (right knee) and 65 (left knee) degrees. See January 2013 VA Examination Report. This finding does not even warrant a compensable rating for limitation of flexion under DC 5261, as flexion limited to 60 degrees warrants a 0 percent rating. The currently assigned 10 percent ratings for each knee are based on painful motion that is not present to a compensable degree under either of the range of motion codes cited above. The Board has considered whether the Veteran is entitled to a separate compensable rating under DC 5257. The Veteran has complained that his knees give way, and contends that he has been awarded a HISA grant in order to make his bathrooms more accessible. See December 2013 VA Form 21-0958. He has submitted lay testimony with respect to his use of a brace on both knees. His wife has stated that he “wobbles and shakes” when bending over to pick something up off the floor. See November 2013 VA 21-4138. The Veteran’s knees have been found to be stable upon physical examination, the most recent being in February 2015. However, a July 2016 VA treatment record notes that the Veteran was at “high risk for falls” because of his knees. Given the objective findings regarding instability and the Veteran’s competent and credible testimony as to instability, the evidence is at least evenly balanced as to whether he has experienced lateral instability warranting separate compensable ratings under DC 5257. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to separate 10 percent initial ratings for right and left knee strain under DC 5257 are warranted. A higher rating is not warranted, however, as there is no contention or clinical evidence that such instability is of a moderate or severe nature, and where contemporary VA examination reports have not found objective evidence of instability. The Board therefore finds that the symptoms most nearly approximated slight lateral instability during the pendency of the claim and the preponderance of the evidence reflects that they did not more nearly approximate moderate instability. Thus, initial separate ratings of 10 percent, but no higher, for left and right knee lateral instability are warranted under DC 5257. The remaining knee diagnostic codes are inapplicable. Diagnostic Code 5256 does not apply, as the medical records do not show any finding of ankylosis. Diagnostic Code 5262 for malunion of the tibia and fibula is not relevant, as this kind of impairment is not shown. There has been no X-ray or MRI evidence of dislocation of semilunar cartilage such that a separate rating or higher rating under DCs 5258 and 5259 would be applicable. The Board has also considered whether the Veteran’s knee disabilities result in functional loss. It is not disputed that the Veteran has limitation of motion of the knees and chronic knee pain. The January 2013 VA examiner noted objective evidence of bilateral pain at the endpoint of range of motion testing with respect to flexion. The January 2013 examiner noted less movement than normal, incoordination, pain, disturbance of locomotion, and interference with sitting, standing and/or weight bearing following repetitive testing. However, he opined that there would be no additional limitation of motion due to such increased symptoms. The February 2015 examiner declined to assess for functional loss during flare-ups or after repetitive testing since the examination did not take place under those circumstances. VA treatment records are absent findings of a loss of range of motion on any flare-ups. Thus, although the Veteran experiences pain with motion and additional symptoms with repetitive use over time, such symptoms do not produce additional functional loss such that the Veteran’s service-connected knee disabilities manifest to a degree that more nearly approximated the criteria for a higher disability rating under the relevant rating criteria. The Board has also considered whether the schedular evaluations are inadequate. The clinical examiners, including most recently in February 2015, have not identified any unusual or otherwise exceptional symptoms. The primary symptoms of pain, instability, and occasional swelling are contemplated by the schedular rating criteria. Review of VA treatment records dated from January 2013 to December 2015 do not identify any extraordinary symptoms. Although limitation of activities, such as walking, and use of a brace are not specifically noted in the rating schedule, it is clear the Veteran’s activities are limited due to his knee pain and decreased motion, all of which are accounted for by the rating schedule. See Spellers v. Wilkie, 2018 U.S. App. Vet (September 7, 2018) (holding that the symptoms of sciatica that caused the Veteran to use assistive devices are contemplated by the schedular rating criteria). 10. Entitlement to a rating in excess of 10 percent for GERD GERD is rated pursuant to 38 C.F.R. § 4.114 DC 7346 as analogous to “hiatal hernia.” A 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combination productive of severe impairment of health. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is warranted for two or more of the symptoms for the 30 percent level of less severity. The criteria associated with DC 7346 are conjunctive, not disjunctive. As a result, all criteria must be met for a higher evaluation. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013) (holding that the conjunctive “and” in a diagnostic code as opposed to the disjunctive “or” required that all elements be met). The evidence shows the Veteran’s primary disability is his GERD and esophageal varices, the symptoms of which overlap such that they are evaluated as one disability under DC 7346. When resolving reasonable doubt in the Veteran’s favor, the Board finds that a 30 percent rating is warranted as the Veteran’s symptomatology approximately equates to a considerable impairment of health if he does not take his medication daily. At the January 2013 VA examination, the Veteran reported experiencing heartburn, dysphagia, reflux, regurgitation, substernal arm or shoulder pain, anemia, nausea, and vomiting. The examiner described the Veteran’s condition as “severe.” He noted that the Veteran had to change medication multiple times, and that he often increased the dose. The Board finds that his regular use of medication is supportive of a 30 percent rating. See Jones v. Shinseki, 26 Vet. App. 56, 62 (2012) (ameliorative effect of medication not to be considered if not contemplated by rating criteria). The preponderance of the evidence is against an even higher 60 percent rating. The February 2013 VA examiner found no impact on work from GERD. Thus, there is no indication that, in the absence of medication, even more severe impairment warranting a 60 percent rating would have been present. And, although merely examples, many of the symptoms set forth in the 60 percent rating have not been shown. The Board acknowledges that melena was noted in February 2013, and that it is listed as an active problem in the VA treatment records from that point on. However, the Veteran specifically denied having this symptom in December 2014 and November 2017. The Board also acknowledges that unexplained weight loss was noted in July 2017. However, the evidence does not reflect hematemesis or moderate anemia, or other symptom combinations productive of severe impairment of health. In fact, the Veteran denied vomiting in July 2017 and denied hematemesis in July 2016. No other diagnostic code provides for a higher rating based on the evidence of record. 11. Entitlement to an initial rating in excess of 10 percent for left upper extremity radiculopathy The Veteran’s left upper extremity is evaluated under the rating code for paralysis of the ulnar nerve. The criteria for evaluating the severity or impairment of the ulnar nerve is set forth under DCs 8515 (paralysis), 8615 (neuritis), and 8715 (neuralgia). 38 C.F.R. § 4.124a. Under DC 8515, a 10 percent rating is warranted for mild incomplete paralysis of the ulnar nerve. A 20 percent rating is warranted for moderate incomplete paralysis of the ulnar nerve of the minor (non-dominant) extremity. A 40 percent rating is warranted for severe incomplete paralysis of the ulnar nerve of the minor (non-dominant) extremity. A 60 percent rating for the minor (non-dominant) extremity is warranted for complete paralysis of the ulnar nerve with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. Peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. In order for a rating in excess of 10 percent to be warranted, the Veteran’s disability would have to be manifested by moderate incomplete paralysis of the ulnar nerve of the minor (non-dominant) extremity. At his January 2013 VA examination, the Veteran reported mild pain, mild numbness, and moderate paresthesias. Strength and sensory testing were normal. Reflexes were hypoactive. The examiner described this condition as mild. The February 2015 VA examiner noted that the Veteran had no symptoms of radiculopathy in the left upper extremity. He specifically noted that the ulnar nerve was not affected. Strength, sensory, and reflex testing were all normal. The examiner concluded that the Veteran’s lower extremity peripheral neuropathy does not impact his ability to work. None of the VA treatment records or examinations show muscle atrophy. A rating in excess of 10 percent is not warranted in the absence of any findings of moderate incomplete paralysis of the ulnar nerve. Effective Dates Unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. An exception to the general rule applies where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of the claim for increased compensation. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400 (o)(2). Under these circumstances, the effective date of the award is the earliest date at which it was ascertainable that an increase occurred. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400 (o)(2); Harper v. Brown, 10 Vet. App. 125, 126 (1997). The question of when an increase in disability is factually ascertainable is based on the evidence in the veteran’s claims folder. Quarles v. Derwinski, 3 Vet. App. 129, 135 (1992). If the increase occurred more than one year prior to the claim, the increase is effective the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. U.S.C. §5110(b)(2); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. §3.400 (o); VAOPGCPREC 12-98 (1998). If no notice of disagreement is filed within the prescribed period, the action or determination shall become final and the claim will not thereafter be reopened or allowed, except as may otherwise be provided by regulations not inconsistent with this title. 38 U.S.C. § 7105 (c). There are, however, two exceptions to the rule of finality – the reopening of a claim based upon new and material evidence under 38 U.S.C. § 5108, and revision of a decision based upon clear and unmistakable error (CUE) under 38 U.S.C. § 5109A. Cook v. Principi, 318 F.3d 1334, 1336 (Fed. Cir. 2002). If new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. A claimant may reopen a finally adjudicated claim by submitting new and material evidence. 38 C.F.R. § 3.156 (a). Effective March 24, 2015, VA amended its regulations to require that all claims governed by VA’s adjudication regulations be filed on a standard form. The amendments implement the concept of an intent to file a claim for benefits, which operates similarly to the informal claim process, but requires that the submission establishing a claimant’s effective date of benefits must be received in one of three specified formats. The amendments also eliminate the constructive receipt of VA reports of hospitalization or examination and other medical records as informal claims to reopen under 38 C.F.R. § 3.157. See 79 Fed. Reg. 57,660 (Sept. 25, 2014) (now codified at 38 C.F.R. §§ 3.1 (p), 3.151, 3.155). The amendments apply only to claims filed on or after March 24, 2015. Because the Veteran’s claims were received by VA prior to that date, the former regulations apply. For appeals filed prior to March 24, 2015, any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA from a claimant may be considered an informal claim, provided it identify the benefit sought. 38 C.F.R. § 3.155 (a) (2017). Under the former 38 C.F.R. § 3.157, once a formal claim for pension or compensation had been allowed or a formal claim for compensation disallowed for the reason that the service-connected disability was not of a compensable degree, the receipt of VA hospitalization or examination reports and other medical records could be regarded as informal claims for increase or to reopen a previously denied claim. See 79 Fed. Reg. 57660, 57696 (Sept. 25, 2014). 12. Entitlement to an effective date earlier than February 13, 2012 for the grant of service connection for cervical intervertebral disc syndrome with arthritis 13. Entitlement to an effective date earlier than February 13, 2012 for the grant of service connection for left upper extremity radiculopathy The record on appeal shows that on February 13, 2012, the RO received the Veteran’s claim of service connection for a neck condition. The record on appeal contains no indication that the Veteran filed an earlier claim and he has not contended otherwise. In a March 2013 rating decision, the RO granted service connection for cervical intervertebral disc syndrome and left upper extremity radiculopathy, effective February 13, 2012, the date of receipt of the Veteran’s claim. The Veteran has appealed the effective date assigned by the RO. Neither he nor his attorney, however, has submitted any evidence or argument in support of the appeal, other than to indicate that the Veteran seeks the maximum benefit. Under the undisputed facts of this case, however, the Veteran is currently in receipt of the earliest effective date legally available. As set forth above, the RO has assigned an effective date of February 13, 2012, for the award of service connection for a cervical spine disability and left upper extremity radiculopathy, corresponding to the date of receipt of the Veteran’s claim. The Veteran has pointed to no earlier claim, formal or informal, and a review of the record reveals no communication which could be construed as a claim of service connection for these disabilities prior to February 13, 2012. See 38 C.F.R. §§ 3.151, 3.155. There is no legal basis for an earlier effective date for the award of service connection for the Veteran’s cervical spine disability and left upper extremity radiculopathy. 14. Entitlement to an effective date earlier than September 30, 2011 for the grant of service connection for left knee strain 15. Entitlement to an effective date earlier than September 30, 2011 for the grant of service connection for right knee strain 16. Entitlement to an effective date earlier than September 30, 2011 for the grant of service connection for lumbar osteoarthritis The Veteran’s service connection claim for knee and back disabilities was originally denied in a November 1997 rating decision. The RO found no evidence in the service treatment records that he was diagnosed with a chronic knee disability while in service. The RO also found that low back pain, congenital scoliosis, spina bifida, and spondylolisthesis existed prior to service and were not permanently worsened as a result of service. The Veteran did not appeal this decision. Therefore, it is final. On September 30, 2011, the RO received the Veteran’s petition to reopen service connection for knee and back disabilities. The Veteran underwent a VA examination in January 2013, in which a positive medical opinion was provided. The RO granted service connection for left knee strain, right knee strain, and lumbar osteoarthritis in March 2013, assigning a 10 percent rating for each disability, effective September 30, 2011. The Veteran appealed the rating and effective date assigned for all three disabilities. Based on a careful review of the record, the Board finds there is no evidence to support the assignment of an effective date earlier than September 30, 2011 for the grant of service connection for left knee strain, right knee strain, and lumbar osteoarthritis. The date of his petition to reopen service connection is the date that entitlement to benefits begins (unless entitlement arose later than the date of the claim). In this case there is no evidence that the Veteran filed a petition to reopen service connection for a knee or back disability prior to September 30, 2011. The Veteran does not contend that there was clear and unmistakable error in the November 1997 decision. He makes no allegation that he submitted a timely notice of disagreement, that new and material evidence was added the record within one year of the November 1997 determination, or that he had provided any document to VA prior to September 30, 2011, that should be considered as an application to reopen the previously denied claims. 17. Entitlement to an effective date earlier than February 13, 2012 for the award of a 20 percent rating for status post left clavicle fracture In November 1997, the RO granted service connection for status post left clavicular fracture and assigned a noncompensable rating, effective September 30, 1997. The November 1997 rating decision became final, as the Veteran did not appeal that determination or submit any pertinent evidence within the appeal period. On February 20, 2011, the Veteran initiated a claim for increased rating for his service-connected left clavicle. In the March 2013 rating decision on appeal, the RO increased the Veteran’s rating for status post left clavicle fracture to 10 percent, effective February 20, 2011. Initially, the Board finds that February 20, 2011 is the appropriate date of claim. The Board finds that there was no pending claim for an increased rating for status post left clavicular fracture prior to that date. In addition, the Board notes that the record does not contain any communication or medical evidence that could be construed as a claim for increased rating for the left clavicle disability. As noted above, an effective date for an increase in compensation can only predate the date of claim if there is a “factually ascertainable” increase in the condition within the year prior to the date of claim. Thus, it is necessary to determine whether the Veteran’s left clavicle increased in severity sometime between February 20, 2010, and February 20, 2011. The evidence of record does not contain any medical evidence regarding the Veteran’s left clavicle during this time period. REASONS FOR REMAND 1. Entitlement to service connection for tinnitus The evidence shows that the Veteran has a current disability. An August 2013 VA audiological examination report noted recurrent tinnitus. Concerning the etiology of the Veteran’s tinnitus, the Board notes that the Veteran was provided a VA audiological examination in August 2013. The Veteran reported that his tinnitus began at least 15 years earlier. The examiner indicated that it was “less likely than not” caused by or a result of military noise exposure. The rationale was that there was no hearing loss during service and that the Veteran currently has normal hearing. As VA has conceded in-service acoustic trauma, the Board finds that a supplemental medical examination is needed. 2. Entitlement to service connection for a sleep disorder, to include sleep apnea The Veteran contends that he has struggled with insomnia since service. In the alternative, he contends that he has a sleep disorder secondary to a service-connected disability. An April 1993 STR shows that the Veteran reported having trouble falling asleep. He was diagnosed with insomnia. Post-service VA treatment records show complaints of insomnia, with the Veteran reporting in March 2013 that his psychiatric medications “helped the most.” These records also contain a diagnosis of obstructive sleep apnea. The February 2013 VA esophageal examination shows that the Veteran reported a sleep disturbance caused by GERD. The elements required for affording the Veteran a VA examination have been met, and remand is required. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 3. Entitlement to service connection for a left shoulder disability (other than status post left clavicle fracture) In March 2013, the RO granted denied service connection for a left shoulder disability (other than status post left clavicular fracture). In December 2013, the Veteran filed an NOD. No SOC has yet been issued on this appeal and therefore it is remanded for that purpose. See Manlincon v. West, 12 Vet. App. 238 (1999). 4. Entitlement to TDIU A total disability rating for compensation based upon individual unemployability may be assigned where the schedular rating is less than total when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. A veteran is eligible for a rating of TDIU if either one service-connected disability is rated at least 60 percent disabling or multiple service-connected disabilities yield a combined rating of 70 percent (with at least one of those disabilities rated 40 percent or more). 38 C.F.R. § 4.16 (a). The Veteran fails to meet the threshold rating requirements of 38 C.F.R. § 4.16 (a) even when considering disabilities resulting from common etiology. Nevertheless, entitlement to TDIU on an extraschedular basis may be considered when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16 (b). Regarding his education, in a February 2014 VA Form 21-8940, the Veteran reported having completed one year of college. He worked as a broadcasting consultant before owning a home remodeling business. He has been unemployed for several years. VA has determined that vocational rehabilitation is not reasonably feasible given the Veteran’s disabilities. See March 2014 VA Vocational Rehabilitation Memorandum Decision. The Social Security Administration found the Veteran disabled effective January 2014 due to his back disability. An August 2013 Functional Capacity Evaluation performed by VA found that the Veteran was capable of between sedentary and light employment. The January 2013 VA examiner concluded that the Veteran’s knee disabilities “are really affecting ability to do his job.” The February 2015 VA examiner found that the Veteran’s lumbar spine disability impacts any work that involves manual labor. In light of this evidence, the Board finds that there is an indication in the record that the Veteran’s service-connected disabilities have interfered with his ability to maintain or obtain substantially gainful employment of the type he has previously done. The Board is prohibited from assigning TDIU on the basis of 38 C.F.R. § 4.16 (b) in the first instance without ensuring that the claim was referred to VA’s Director of Compensation Service. Bowling v. Principi, 15 Vet. App. 1 (2001). Thus, remand is warranted for referral to the Director of Compensation Service for consideration of an extraschedular rating under 38 C.F.R. § 4.16 (b). The matters are REMANDED for the following action: 1. Schedule an appropriate VA examination to determine the nature and etiology of the Veteran’s tinnitus. The clinician must opine whether the condition is at least as likely as not related (50 percent probability or greater) to the Veteran’s active service, including conceded in-service noise exposure. A complete rationale for any opinion must be provided. 2. Schedule an appropriate VA examination to determine the nature and etiology of any currently sleep disorder, to include insomnia and obstructive sleep apnea. Determine whether it is at least as likely as not (50 percent probability or greater) that any currently diagnosed sleep disorder manifested in service or is otherwise related to active service. The examiner should address the April 1993 STR and relevant VA treatment records. A complete rationale for any opinion must be provided. 3. Refer to the Director of Compensation Service the matter of whether TDIU is warranted on an extraschedular basis pursuant to 38 C.F.R. § 4.16 (b). 4. Issue an SOC addressing the issue of entitlement to service connection for a left shoulder disability (other than status post left clavicle fracture). If an appeal is perfected, this issue should be returned to the Board, if otherwise in order. Otherwise the appeal should be closed by the originating agency. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R.N. Poulson, Counsel