Citation Nr: 18152323 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 15-03 589 DATE: November 21, 2018 ORDER Service connection for a bilateral knee disorder is denied. Service connection for diabetes mellitus is denied. A rating in excess of 10 percent for tinnitus is denied. Compensation under 38 U.S.C. § 1151 for left toe amputations is denied. REMANDED Entitlement to a compensable rating for bilateral hearing loss is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The most probative evidence of record shows that a bilateral knee disability, to include calcific enthesopathy of the bilateral knees was not manifested during service or within one year after service, and such disability is not otherwise shown to be a result of active military service. 2. The most probative evidence of record indicates that diabetes mellitus was not shown in service or for many years thereafter, and it fails to link the Veteran’s current diabetes to service. 3. The Veteran is in receipt of a 10 percent rating for tinnitus, which is the maximum schedular rating under the applicable rating criteria, and the rating schedule is adequate to evaluate such disability. 4. Competent medical evidence reflects that the Veteran’s left toe amputations were not proximately due to carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA, or the result of an event that was not reasonably foreseeable. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for a bilateral knee disability have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 2. The criteria for establishing entitlement to service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1110, 1131, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 3. There is no legal basis for the assignment of a rating in excess of 10 percent for tinnitus. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321 (b)(1), 4.3, 4.7, 4.87, DC 6260 (2018); Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). 4. The criteria for entitlement to compensation benefits, pursuant to the provisions of 38 U.S.C. § 1151 for left toe amputations, have not been met. 38 U.S.C. § 1151 (2012); 38 C.F.R. § 3.361 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from February 1982 to November 1988. This appeal to the Board of Veterans' Appeals (Board) arose from Department of Veterans Affairs (VA) Regional Office (RO) rating decisions in December 2009 and March 2015. The December 2009 rating decision granted service connection for tinnitus, evaluated as 10 percent disabling, and service connection for bilateral hearing loss with a noncompensable evaluation. The December 2009 decision also denied service connection for a bilateral knee disability. The Veteran perfected an appeal. See December 2010 Notice of Disagreement (NOD); January 2015 Statement of the Case (SOC); January 2015 VA Form-9. The March 2015 rating decision denied service connection for adult onset diabetes mellitus, entitlement to compensation under 38 U.S.C. § 1151 for left toe amputations, and entitlement to TDIU. The Veteran perfected an appeal. See March 2015 Notice of Disagreement (NOD); July 2017 Statement of the Case (SOC); August 2017 VA Form-9. The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claims and what the evidence in the claims file shows, or fails to show, with respect to those claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. 1110, 1131; 38 C.F.R. 3.303 (a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Certain chronic diseases, including diabetes mellitus and arthritis, can be presumed related to service when a veteran has certain qualifying service and the chronic disease becomes manifest to a degree of 10 percent within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2018). This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. § 1113. If there is no evidence of a chronic condition during service or the applicable presumptive period, then a showing of continuity of symptomatology from the time of service until the present may serve as an alternative method of establishing the second and/or third element(s) of a service connection claim. 38 C.F.R. § 3.303 (b). The theory of continuity of symptomatology in service connection claims is limited to those disabilities explicitly recognized as "chronic" by regulation. See Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 1. Bilateral knee disability The Veteran seeks entitlement to service connection for a bilateral knee disability. He contends that he injured his right knee in service and reported intermittent right knee pain on his separation physical. The Veteran also contends that he suffered an insect bite to his left knee in service, which led to a major infection in the left knee compartment. He asserts that he has daily left knee pain and loss of range of motion as a result. See September 2008 Statement in Support of Claim. Service treatment records (STRs) document that the Veteran injured his left knee in June 1983. The Veteran reported that he hit his knee on the frame of a truck. Examination revealed pain around the knee with inflammation, evidence of slight drainage, and limited range of motion. Additional symptoms of moderate swelling, redness, tenderness, and some discoloration were noted and assessments of prepatellar cellulitis and bruised knee were rendered. Irrigation and drainage was performed. See Service Treatment Records. An October 1984 STR documents that the Veteran’s right leg was extremely tender. Irrigation and drainage was performed and the Veteran was placed on a temporary profile of no running, jumping, or marching for seven days. The Veteran was seen again on October 17, 1984 for an issue with the right anterior tibia. The leg displayed redness and was tender and warm to touch. There was an abcess at the irrigation and drainage site which was closing without sign of infection. There was an indication that additional irrigation was performed and an October 23, 1984 STR noted that the abcess was healing. Id. A November 1984 STR documents that the Veteran reinjured his right leg while unloading a freight car. Id. In July 1986, the Veteran reported bilateral knee pain when working and after running. He reported that pain started in the morning before gradually going away and then starting again after runs in the evening. Examination of the knees was normal with normal range of motion. Id. On his November 1988 separation examination, the Veteran stated that he was in good health but reported swollen painful joints. He complained of distal leg pain and cramps from running; however, he responded “don’t know” to a question inquiring if he had symptoms of trick or locked knee. Id. Post-service, a May 2009 treatment note documents that the Veteran believed his joint pain (including his knees) might be related to recently starting metformin for his diabetes mellitus. See VA Treatment Records. A November 2009 treatment record notes an assessment of calcific enthesopathy at the insertion of the quadriceps. Id. A VA examination was performed in December 2009. The examiner noted that she reviewed the Veteran’s claims file, including service medical records, and a summary of relevant service treatment records was provided. The examiner noted left knee pain with an onset in 1987. The Veteran reported that he first noticed this symptom after long runs when he experienced burning pain. A lift truck hit the knee in approximately 1984 and the Veteran underwent medical evaluation. The examiner noted that no films had been done on the knee. The Veteran was evaluated by Dr. S. at Twin City Medical, who evaluated the Veteran and requested that he follow-up with VA. The examiner noted that records from Dr. S. were not available in the file. Dr. S. examined both knees, treated with ice, and recommended activity changes. See December 2009 VA Examination Report. The Veteran reported an insect bite to the right leg and knee in 1984. He reported that this resolved for about a year. While stationed in Germany, the Veteran hit his knee and the knee swelled up. The Veteran had fluid taken out of the knee and was given shots, which were possibly cortisone. Since 1987, the Veteran reported that the knee had gotten progressively worse. The Veteran was unable to kneel and reported pain 8-9 out of 10, which felt like his whole knee was on fire, in addition to pain and tenderness under the right knee cap. The right knee was swollen when the Veteran was seen by Dr. S. Id. On physical examination, the right knee displayed bony joint enlargement, crepitus, tenderness, and instability. There was crepitation, mass behind the knee, and evidence of clicks or snaps. The examiner noted patellar abnormality in the form of mild dislocation/subluxation, abnormal tracking, and subpatellar tenderness at the superior pole of the patella. Right knee range of motion revealed flexion of 0 to 113 degrees and normal extension. On the left knee, there were findings of crepitation and mild dislocation/subluxation. Left knee range of motion was from 0 to 120 degrees with normal extension. X-rays revealed right knee calcific enthesopathy. The examiner noted that calcifications around the superior and inferior patella probably represented calcific enthesopathy. No effusions or fractures were identified. X-ray of the left knee showed calcific enthesopathy at the insertion of the quadriceps tendon, with no other abnormalities. Standing weight-bearing views of both knees were obtained and revealed normal joint spaces with no fractures. Id. The diagnosis was bilateral quadriceps enthesopathy. Problems associated with the diagnosis were bilateral knee pain. The examiner noted significant effects on occupation in the form of decreased mobility, problems with lifting and carrying, lack of stamina, weakness or fatigue, decreased strength, and lower extremity pain. Id. The examiner stated that there was an in-service left knee injury which resulted in a cellulitis. There was evidence of a separate right knee injury from an infection in the proximal tibial area which required drainage and packing, though no mention of etiology of infection was made. At the December 2009 examination, the Veteran stated that the insect bite was to the right knee. On radiologic examination, there was evidence for calcific enthesopathy of both the right and left quadriceps tendons. The records since discharge were silent for any diagnosis or treatment related to the Veteran’s knees, though the Veteran reported that he had seen a physician for his knee problems. The examiner stated that calcific enthesopathy was unrelated to prior trauma or infection, but may be related to systemic disease. The bilateral calcific enthesopathy was not caused by or the result of the service related knee injuries or insect bite. Id. A September 2010 treatment record documents that the Veteran was seen in rheumatology for joint pain and stiffness. Musculoskeletal examination revealed Heberden’s and Bouchard’s nodes bilaterally. There was no synovitis. The Veteran had normal range of motion in all peripheral joints. The knee examination revealed medial and patellofemoral compartment tenderness in both knees. SI tenderness was not noted and SLR was negative. Range of motion was reduced at the lumbosacral spine. Assessments of chronic mechanical low back pain and osteoarthritis complicated by obesity were noted. An October 2010 treatment record documents that the Veteran was seen by Dr. C.O. for joint pain, including in the knees. The Veteran was advised to follow up with rheumatology. Calcific enthesopathy was noted. In November 2010, the Veteran reported pain and stiffness. In his December 2010 substantive appeal, the Veteran reported that doctors told him that his knee disorder was caused by injuries from many years ago, and the calcium buildup in his knee was a result of these injuries and could have been caused by the spider bite he suffered while in the Army. See December 2010 VA Form-9. An October 2011 VA treatment record notes examination of the right knee revealed minimal tenderness to the medial aspect of the right knee with no deformity or swelling. The VA clinician, Dr. M.H. assessed internal derangement of the right knee, a meniscal tear injury, and possible osteoarthritis. A subsequent MRI that same day revealed no evidence of osteoarthritis of the right knee but documented calcifications at tendon attachments along the patellar poles. An April 2012 VA treatment record documents imaging of the left knee which revealed no significant abnormality of the bone, joints, or adjacent soft tissues. In a September 2012 correspondence, the Veteran’s representative submitted medical records which he asserted showed arthritis and severe knee pain. Specifically, he referred to reports from an arthritis clinic which he contends show that the Veteran has been diagnosed with osteoarthritis of the knees. He stated that the initial VA determination did not contain any reference to osteoarthritis as a service-connected disability and stated that the Veteran’s knee pain was clearly associated with his osteoarthritis. Further, he pointed to records from the Louis Stokes VAMC which noted right knee pain with a history of chronic bilateral knee pain. He quoted Dr. M.H. as stating “pt hit by a truck in the military injuring right and left knee and since then has had problems with his knees since.” He stated that Dr. M.H. went on to diagnose the Veteran with internal derangement of the right knee and possible osteoarthritis. See September 2012 Correspondence. In May 2013, the Veteran’s representative asserted that the Veteran had been diagnosed with osteoarthritis of the knees and asserted that the Veteran’s knee pain was associated with his osteoarthritis. Analysis As an initial matter, the existence of a present disability is established through the Veteran's medical treatment records and examination reports produced during the course of his appeal. The evidence shows that the Veteran has a current diagnosis of calcific enthesopathy of the bilateral knees. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Further, the record establishes in-service injuries and treatment of the Veteran's bilateral knees. Thus, the remaining question before the Board is whether the Veteran's currently diagnosed calcific enthesopathy of the bilateral knees is related to his period of service. Unfortunately, the Board concludes that the preponderance of the evidence is against a finding that the Veteran's bilateral knee disorder is related to his military service. In this regard, the Board finds the December 2009 VA examination and opinion to be highly probative to the issue at hand. The Board notes that the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, his knowledge and skill in analyzing the data, and his medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the December 2009 VA examiner’s conclusions are shown to have been based upon a review of the Veteran's claims file, including service treatment records, available private treatment records, and VA treatment records; physical examination; and acknowledgement of the Veteran's lay statements regarding the onset of his symptoms. Moreover, the VA opinion is accompanied by a sufficient explanation and reference to pertinent evidence of record. The examiner noted the Veteran's in-service injuries and treatment to his knee but opined that the current disability is unrelated to the incidents recorded in-service. Specifically, the examiner diagnosed only calcific enthesopathy and indicated that while such condition may be related to systemic disease, it was unrelated to prior trauma or infection such as that documented in the Veteran’s STRs. Furthermore, the examiner’s conclusions are consistent with the evidence of record, including VA treatment records, which show ongoing treatment for bilateral knee pain but do not relate symptoms of bilateral knee pain or the diagnosis of calcific enthesopathy to service. The examiner demonstrated a detailed understanding of the record, including the lay testimony, but ultimately reached the conclusion that the Veteran's current bilateral knee disorder is not related to his period of service. In the precedent decision of Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), the Court held that the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion. In this case, the opinion provided by the VA examiner provides a solid discussion of the Veteran's contentions, the objective medical history of his bilateral knee symptoms, and a thorough rationale with sound reasoning and conclusions. For these reasons, the opinion by the December 2009 VA examiner is afforded great probative value. The Board acknowledges the September 2012 letter from the Veteran’s representative which asserts both that the Veteran has a diagnosis of osteoarthritis of the knees and that his condition has been linked to service. In regard to a diagnosis of osteoarthritis, such diagnosis is not supported by the evidence of record. A September 2010 rheumatology treatment record included an assessment of osteoarthritis complicated by obesity; however, it was unclear that this assessment was specifically in reference to the Veteran’s knees. Additionally, although an October 2011 treatment record by Dr. M.H. assessed possible right knee osteoarthritis, a MRI conducted the same day revealed normal right knee imaging. Imaging of the left knee in April 2012 revealed no significant abnormality of the bone, joints, or adjacent soft tissues. Thus, although osteoarthritis was considered as a possible diagnosis, subsequent imaging ruled out such diagnosis and the evidence of record contains no findings of osteoarthritis confirmed by radiologic imaging. In regard to a link between the Veteran’s diagnosed calcific enthesopathy and service, the Veteran has asserted that Dr. M.H. provided a link through his statement that the Veteran was “hit by a truck in the military injuring right and left knee and since then has had problems with his knees.” The Board suspects that this statement was meant to document the Veteran’s report of his medical history rather than to provide a positive nexus between the Veteran’s in-service injury and his current bilateral knee disorder. Nonetheless, even accepting the statement as a positive nexus, the Board finds that it is not supported by rationale and as such affords it less probative value than the opinion of the December 2009 VA examiner, discussed above. The Board has considered the Veteran's lay statements in evaluating his claim. The Board acknowledges the Veteran's assertions that he has experienced knee pain since service and his assertions that his bilateral knee disorder is related to his period of service; specifically, documented in-service injuries and treatment to both knees. In this regard, he is competent to report symptoms, such as pain and limitation of motion, that require only personal knowledge as they come to him through his senses as well as any diagnosis reported to him by a medical professional. See Layno v. Brown, 6 Vet. App. 465, 47 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Veteran, as a lay person, is generally not competent to link his symptoms to a specific diagnosed disability or to relate them to any instance of his military service. While it is in error to categorically reject layperson evidence as incompetent, the Board is allowed to consider the facts of a particular case to determine the layperson's competence. See Davidson v. Nicholson, 581 F.3d 1313 (Fed. Cir. 2009). One factor to consider is the complexity of the question to be determined. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (providing an example at footnote 4 that a layperson would be competent to diagnose a simple condition such as a broken leg but not to diagnose a form of cancer.). In this regard, the Veteran's statements as to the relationship between his current bilateral knee disorders, diagnosed as calcific enthesopathy, are not within the realm of knowledge of a layperson. Rather, the nature and causation of a knee disorder is a complex question that requires expertise. There is no indication that the Veteran possesses such specialized knowledge, and therefore, he is not competent in this regard. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board accords his statements regarding the nature and etiology of his bilateral knee disorder no probative weight. Based on the foregoing, the Board concludes that the preponderance of the evidence is against a finding that the Veteran's current bilateral knee disorder, diagnosed as calcific enthesopathy, was present in service or is a result of service. The Board has considered the Veteran's assertion that his current bilateral knee disability is related to service, to include the documented injuries and treatment in service. However, the VA examiner who examined the Veteran and reviewed his claims file concluded that the Veteran's current bilateral knee disorder is not a result of his service. In sum, the weight of the competent and probative evidence does not establish that the Veteran's bilateral knee disorder is related to his military service. Accordingly, service connection is not warranted for a bilateral knee condition on any basis. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b) (West 2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56. 2. Diabetes mellitus The Veteran seeks entitlement to service connection for adult onset diabetes mellitus. At the outset, the Board notes that the Veteran has not been afforded a VA examination in regard to his claim of service connection for adult onset diabetes. However, a VA examination is not needed in every case. In McLendon v. Nicholson, the Court held that the Secretary must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2), 38 C.F.R. § 3.159 (c)(4)(i). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. Id. at 83. In this case, as will be discussed further below, although the Veteran has a current diagnosis of diabetes mellitus, the only evidence of record that the Veteran’s diabetes is related to his military service are the Veteran's own general conclusory statements, which do not meet the low threshold of an indication that the claimed disability is due to service. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (distinguishing cases where only a conclusory generalized statement is provided by the veteran and rejecting the theory that medical examinations are to be routinely and virtually automatically provided to all veterans in disability cases involving nexus issues). Therefore, the Board finds that a remand to obtain a VA examination for this issue is not necessary. Service treatment records contain no complaints, treatment, or diagnosis for diabetes mellitus. The Veteran’s November 1988 separation examination showed no sugar on urinalysis testing and no abnormalities were noted by the examining physician. VA treatment records document that the Veteran has received ongoing treatment for diabetes. The exact date of diagnosis is unclear from the record. A May 2009 treatment record notes that the Veteran had recently started taking metformin for his diabetes. A July 2011 treatment record notes that the Veteran was seen for diabetes that he had had for one year. An April 2012 treatment record notes diabetes duration of less than a year and reports onset in June 2011. However, a May 2013 treatment record notes a duration of diabetes of 1 to 5 years with onset in April 2008. Thus, the first objective post-service evidence of a diagnosis of diabetes is in April 2008, which is almost 20 years after the Veteran's period of service. As diabetes was not shown for many years after the Veteran's period of service, this weighs against a claim that it was related to service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). Moreover, at no time has any treating provider related the Veteran's diabetes to his period of service. Thus, although the Veteran has a current diagnosis of diabetes, the Board finds that the most probative evidence supports the conclusion that the Veteran's diabetes did not manifest in service or for a significant period thereafter. For his part, the Veteran has not alleged that his diabetes began in service. The Veteran submitted a claim for diabetes on April 28, 2014, however he did not state any basis for why he believed his diabetes was related to service. The Veteran submitted an amended version of his claim on April 30, 2014, in which he listed diabetes, adult onset, as secondary to his toe amputations. The Veteran’s claim to entitlement to compensation benefits, pursuant to the provisions of 38 U.S.C. § 1151, for left toe amputations, is discussed below. However, the Board notes that the Veteran underwent left toe amputation in February 2014. Thus, the evidence shows that the Veteran’s diabetes diagnosis, in approximately April 2008, predated his amputation by 6 years. Additionally, the evidence suggests that the circumstances leading to the Veteran’s left toe amputation was due, in part, to his diabetes rather than the other way around. Thus, there is no basis for secondary service connection. In regard to continuity of symptoms, the Board finds that the Veteran's diabetes is properly afforded such consideration, as it is one of the enumerated conditions in 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, due to the finding that there is no credible or probative evidence of continued diabetes symptoms or diagnosis for many years after service, service connection based on continuity of symptomatology is not warranted. The Board acknowledges that lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, diabetes falls outside the realm of common knowledge of a lay person. Thus, while the Veteran can competently report symptoms of diabetes, an actual diagnosis of diabetes requires objective testing to diagnose, and can have many causes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Thus, the Board finds that the Veteran is not competent to diagnose the onset or cause of his diabetes. In sum, the Board finds that the most competent and probative evidence indicates that diabetes was not shown in service or for many years thereafter, and the most probative evidence fails to link the Veteran's current diabetes to service. Accordingly, service connection for diabetes is not warranted on any basis. In reaching the conclusions above, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Increased Ratings Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The determination of whether an increased disability rating is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, the Court has determined that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). In its evaluation, the Board shall consider all information and lay and medical evidence that is of record. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b). 1. Entitlement to an initial rating in excess of 10 percent for tinnitus The Veteran seeks an increased rating for recurrent tinnitus, which is currently assigned a 10 percent rating under 38 C.F.R. § 4.87, Diagnostic Code 6260. Under 38 C.F.R. § 4.87, Diagnostic Code (DC) 6260, the sole and maximum schedular rating for recurrent tinnitus is 10 percent. Note 1 to DC 6260 provides that a separate evaluation for tinnitus may be combined with an evaluation under diagnostic codes 6100 (hearing loss), 6200 (otitis media), 6204 (peripheral vestibular disorders), or other diagnostic codes, except when tinnitus supports an evaluation under one of those diagnostic codes. Note 2 provides that only a single evaluation is to be assigned for recurrent tinnitus, whether the sound is perceived in one ear, both ears, or in the head. See also Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). Note 3 provides that objective tinnitus (in which the sound is audible to other people and has a definable cause that may or may not be pathologic) is not to be evaluated under DC 6260, but is to be evaluated as part of an underlying condition causing it. In this case the evidence does not establish, and it is not alleged, that the Veteran had objective tinnitus (as defined in Note 3 to DC 6260) which is perceived by others, and here the Veteran is not service-connected for otitis media or peripheral vestibular disorder. Thus, as the current version of DC 6260 specifically prohibits a schedular evaluation in excess of a single 10 percent rating for tinnitus, however perceived, i.e., in one ear, both ears or in the head, an evaluation in excess of 10 percent for recurrent tinnitus is not warranted as a matter of law in this case. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law and not the evidence is dispositive, the Board should deny the claim on the ground of the lack of legal merit or the lack of entitlement under the law). The Board has reviewed and considered the Veteran's statements regarding the severity of his tinnitus and the Board acknowledges that the Veteran, in advancing this appeal, believes that the disability has been more severe than the assigned disability rating reflects. Moreover, he is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). The lay evidence has been considered together with the probative medical evidence clinically evaluating the severity of his tinnitus symptoms. However, the Veteran has been assigned the maximum schedular rating allowable under the law. Furthermore, the Veteran's tinnitus is not shown (or alleged) to have manifestations or cause impairment not encompassed by the schedular criteria. The Veteran's reports of ringing are the basis for the 10 percent rating for tinnitus assigned. Therefore, the schedular criteria are not inadequate, and referral for extraschedular consideration is not necessary. 3. 38U.S.C. 1151 for left toe amputations The Veteran seeks disability compensation pursuant to U.S.C. § 1151 for an amputation of the left fifth toe in February 2014 and a further resection of excess bone in July 2014, both of which were performed at the VA Medical Center in Wade Park, Ohio. The Veteran alleges negligence on the part of VA; specifically, he asserts that there was no infection in the bone of his left fifth toe and that, as such, the amputations were unnecessary. Pursuant to 38 U.S.C. § 1151, if VA hospitalization or medical or surgical treatment results in additional disability or death that is not the result of the claimant's own willful misconduct or failure to follow instructions, compensation may be awarded in the same manner as if the additional disability or death were service connected. See 38 C.F.R. §§ 3.361. A disability is a qualifying additional disability if the disability was caused by VA treatment, and the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the surgical or medical treatment; or the additional disability was not reasonably foreseeable. 38 U.S.C. § 1151 (a) (2012). To determine whether the veteran has additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy (CWT) program upon which the claim is based to the veteran's condition after such care, treatment, examination, services, or program has stopped. VA considers each involved body part or system separately. 38 C.F.R. § 3.361 (b). Under 38 C.F.R. § 3.361, to establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part, it must be shown that the VA failed to exercise the degree of care that would be expected of a reasonable health care provider. Under 38 C.F.R. § 3.361 (c), a claim based on additional disability due to surgical or medical treatment must meet the causation requirements. To establish causation, the evidence must show that the VA's treatment caused the additional disability. Merely showing that a veteran received treatment and that the veteran has an additional disability does not establish cause. Id. Whether the proximate cause of an additional disability is an event not reasonably foreseeable must be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable, but must be one that a reasonable health care provider would not have considered an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with informed consent. 38 C.F.R. § 3.361 (d). Liability under § 1151 may also be established if VA furnished treatment without the informed consent of the veteran or his representative in compliance with 38 C.F.R. § 17.32. Minor deviations from the 38 C.F.R. § 17.32 requirements that are immaterial under the circumstances of a case will not defeat a finding of informed consent. Factual Background and Analysis A review of the Veteran’s medical records shows a history of poorly controlled diabetes mellitus, hypertension, dyslipidemia and obesity. The Veteran was seen in the VA podiatry outpatient clinic at the Canton Community Based Outpatient Clinic (CBOC) on January 28, 2014. He reported that he had recently started a new job that required him to wear steal toe boots and had, within the last week, noticed a blister “that just popped.” He stated that he tried wearing an AIR walker boot that had been given to him at his last visit to the clinic, but was told by his supervisor that he had to wear a steel toed boot. The Veteran endorsed numbness, tingling, and burning sensation. He denied pain to the left foot that day. See January 2014 Podiatry Outpatient Clinic Treatment Note. The treating physician noted an ulcer at the plantar aspect of the 5th MPJ of the left foot. The base of the ulcer was granular with some eschar noted. The left foot was slightly erythematous, edematous with some serosanguinous drainage noted. There was no malodor. There was no probing to bone, no tracking, and no undermining, with some calor noted to the left foot. The doctor discussed diagnosis and treatment with the Veteran in detail. She explained the importance of glycemic control, as well as general compliance, and the risks and complications associated with non-compliance, including but not limited to: infection, loss of toe, and loss of limb. She further discussed the need to keep pressure off the ulcer site, properties of wound healing, and instructions for daily wound care. The doctor warned the Veteran about keeping the wound clean and having shoes on at all times. The Veteran indicated that he could not wear his AIR walker boot to work even with a doctor’s excuse. The doctor instructed him to wear the AIR walker boot when not working and to elevate his left foot at work. She indicated that all questions were answered and the Veteran verbalized his understanding. The Veteran refused radiographs as he needed to return to work. He was advised on signs and symptoms of worsening and/or infection and instructed to report to urgent care or to his local ER if any concern arose. The Veteran verbalized his understanding. Id. On February 4, 2014, the Veteran presented for follow-up on his left foot ulcer. The Veteran reported that his sugars were coming down with his new medications and he indicated that he had been wearing his air walker boot at home but was unable to wear it at work. He reported that he elevated his left foot at work and was taking antibiotics as directed. Examination showed an ulcer at the plantar 5th MPJ of the left foot. It was noted that the base of the ulcer was fibrotic. There was a large rim of HPK noted, but no probing to bone, no tracking, no undermining, no erythema, edema, calor, malodor, purulence, proximal streaking or signs of infection. A hemorrhagic callus was noted on the 5th MPJ right. A full thickness debridement to healthy bleeding tissue was performed, although it was unclear if this was being performed on the left foot ulcer or the right foot callus. It was indicated that the doctor explained the importance of daily foot checks as loss of sensation leads to callouses which break down and result in ulcers that may lead to gangrene and amputation. On February 23, 2014, the Veteran presented with worsening right foot erythema and swelling. The Veteran reported that three weeks prior, he sustained a small cut on the sole of his left foot. He was followed by podiatry frequently and last seen on February 4th, at which point his ulcer measured 1.2cm x 1.2cm and had a 3mm depth with a fibrotic ulcer base. It was noted that over the last 24-48 hours, the Veteran experienced increased drainage, malodor, edema, calor, and erythema from the ulcer, extending to the rest of his foot. The Veteran experienced low-grade fevers at home with a temperature of 99.7 degrees and chills but no night sweats. Treatment notes describe an infected ulceration with gas in tissue. It was noted that the abnormal presence of gas in soft tissue could be due to gas producing bacteria. Bony structures were stable. It was noted that if there was high clinical suspicion for osteomyelitis, further evaluation could be considered with bone scan or MRI. Additional treatment notes indicate that the Veteran was admitted for a gangrenous left foot ulcer. The Veteran’s foot was debrided and the 5th toe was partially amputated by podiatry. Post-operative MRI did not show any evidence of remaining osteomyelitis, but it was noted that given that wound and bone cultures grew out MSSA among other gram negatives and anaerobes, per the infectious disease department, the Veteran was switched to a course of IV medications. The Veteran was discharged on February 27, 2014. An April 2014 infectious disease inpatient treatment notes that the Veteran was recently treated for polymicrobial osteomyelitis of the left 5th toe status post amputation, after the Veteran presented with gas gangrene in February 2014, and following treatment with IV ertapenem. It was noted that since that treatment, the Veteran’s wound had been slow to heal with the wound vac. An X-ray of the left foot showed active osteomyelitis of the remaining left 5th digit with pyogen culture now growing MRSA, Enterobacter, and enterococcus. A July 2014 letter from Dr. J.T.M. of the Cleveland VA Medical Center documents that the Veteran was status post open partial 5th ray from a severe diabetic foot infection. He noted that x-rays revealed boney proliferation at the 5th ray amputation site that appeared to be impeding healing. The plan was to perform an additional operation to reset the excess bone and attempt to ellipse the existing wound and close the wound primarily. The doctor indicated that if successful, he expected the surgical incision to be healed and the Veteran to be fully weight-bearing a month after the procedure. See July 2014 Letter of Dr. J.T.M. In July 2014, the Veteran submitted a statement in which he asserted that he presented to the VA hospital on February 23, 2014 and was told that he had a staph infection in his foot that also involved the bone of his little toe. The Veteran reported that the VA doctor informed him that they would need to remove his toe and possibly the entire foot. The Veteran reported that he asked the doctor how she was sure that his bone was infected without any type of testing or x-rays and that the doctor informed him that she was sure there was infection based on her experience. The Veteran indicated that he granted permission to remove the toe if needed but did not grant permission to remove the entire foot without more testing. The Veteran cited a radiology report that noted that bony structures were stable, as well as a postoperative report that was negative for infection in the bone, as evidence that the removal of his toe was un-needed and greatly increased the length of his healing time. A VA medical opinion was obtained in March 2015 from a facility other than the VA center where the Veteran received the treatment in question. The Veteran’s claims file was reviewed. The examiner noted that the Veteran had a history of poorly controlled diabetes mellitus, hypertension, dyslipidemia and obesity. The Veteran presented on February 4, 2014 to the Cleveland VA with an ulcer on his left foot, then ongoing for 3 weeks. X-rays at initial presentation did not show evidence of gas or osteomyelitis. The ulcer was debrided in the office by podiatry, and the Veteran was discharged on oral antibiotics. The Veteran later reported to Cleveland VA urgent care on February 23, 2014 with left foot swelling and infection. Examination of the foot showed evidence of “devitalized tissue.” The Veteran was immediately started on IV antibiotics and podiatry was consulted. X-rays showed soft tissue gas, but no evidence of osteomyelitis. However, based on the podiatrist’s interpretation of the radiographs, cortical erosion was noted to the left fifth metatarsal head and proximal phalanx base, seen on lateral view. See March 2015 VA Medical Opinion. The examiner noted that these were changes suggestive of osteomyelitis. The Veteran was noted to have fever, high ESR and sepsis. He was diagnosed with gas gangrene of the left foot and taken to surgery the same day. Informed consent was obtained prior to the surgery which specifically discussed the possible need for further bone debridement. The surgical report states that “a large amount of milky white and yellow purulent drainage and strong malodor was noted immediately after skin incision was made over the dorsal fifth metatarsophalangeal joint. The tissue within the incision was noted to be non-viable gray in color. Decision was made to proceed with the amputation of the fifth toe and partial fifth metatarsal.” Surgical tissue cultures grew MSSA and bone cultures also showed rare staph aureus. Post-operative MRI did not show osteomyelitis in the remaining tissue, which the examiner noted was expected. The Veteran was treated with IV antibiotics for 6 weeks by infectious disease service for suspected osteomyelitis. Surgical pathology showed ischemic necrosis of the skin with ulceration and severe acute inflammation of the resected margin. The Veteran’s discharge diagnosis on February 28, 2014 was “foot osteomyelitis.” Id. The Veteran presented with recurrent ulcer on the foot in April 2014. An X-ray on April 11, 2014 showed acute osteomyelitis of the remaining fifth metatarsal, despite treatment for 6 weeks with IV antibiotics, which ended on April 6, 2014. Id. The examiner noted that review of the literature showed that radiographic findings may be subtle or absent in early bone infection. Characteristic radiographic findings for chronic osteomyelitis include cortical erosion. Id. The examiner indicated that she reviewed the Veteran’s case with the staff podiatrist at the Columbus VAMC who concurred that radiographic findings of bone infection could be absent at the time of the Veteran’s presentation. Considering the presence of gas on x-rays and non-viable tissue at the time of the surgery, the decision to amputate the toe was appropriate. Id. Based on review of the above, the examiner stated that it was her opinion that the Veteran clearly had tissue infection and multiple signs of bone infection going on, as evidenced by positive tissue and bone cultures, systemic sepsis, non-viable necrotic tissue during surgery, cortical erosion and lytic changes of bone as per the podiatrist interpretation of x-rays, etc. The Veteran was planned for incision and debridement (I&D) but the preoperative diagnosis included possible osteomyelitis. The decision to remove the toe and partial metatarsal bone was made by the surgeons based on the intra-operative findings (what they saw during surgery). The examiner stated that clinically, the decision sounded appropriate. She noted that this was reinforced by the fact that the Veteran presented with bone infection immediately after finishing 6 weeks of IV antibiotics. If his bone was not infected, there would be no alternate explanation for why he presented with osteomyelitis (bone infection) in April, despite surgical resection of the bone, followed by 6 weeks of IV antibiotic therapy. He had a history of poorly controlled diabetes (A1c was 9.7 in January 2014) and it would have been extremely difficult to control the infection with just antibiotics and wound debridement. Therefore, the examiner opined that there was no evidence of the disability of toe amputation being caused or worsened by the VA treatment due to carelessness, negligence, lack of skill or similar instance of fault. The examiner stated that she did not think that the toe amputation resulted from an event that could not have been reasonably foreseen by a reasonable health care provider. The conclusion was based on the Veteran’s history of poorly controlled diabetes, obesity, and foot ulcer with devitalized tissue. Amputation, in order to prevent spread to vital tissue is common in such cases. There was no failure on the part of VA to timely diagnose or treat the claimed condition; on the contrary, the providers immediately acted on the urgency of the situation. Id. In September 2015, the Veteran submitted a private medical opinion from Dr. D.C. of North Star Orthopaedics. The doctor noted that the Veteran underwent callous excision to his left foot in January 2014 by his podiatric surgeon. Following the procedure, he experienced bleeding and difficulty with healing on the lateral aspect of his left foot. He was placed on antibiotics by his podiatric surgeon and continued to have healing difficulties to his left foot. He was admitted to the VA at Wade Park on February 22, 2014. He was seen by the podiatric surgeon and surgery was recommended on the following morning. The Veteran reported that he was told that he had osteomyelitis of his left fifth toe which would require amputation. He stated that when he spoke with the surgery team the following day, he was told that he also had resection of his left fifth metatarsal and the left fifth toe. The Veteran reports that he continued to have pain to the left forefoot and underwent a second procedure in July 2014. The second procedure was for removal of heterotopic ossification. The Veteran reported that he had an extended healing period and continued pain. See September 2015 Medical Opinion of D.C. A physical examination of the Veteran was performed, and it was noted that he ambulated independently and walked with a slight limp. There were no gross neurologic deficits. He had palpable pulses to the posterior tibialis and dorsalis pedis arteries to both lower extremities. He had well-healed incisions to his left foot, intact sensation to both feet with deep palpation, and decreased sensation to his toes on both feet with light touch. There was tenderness to palpation along the lateral aspect of the left forefoot. Id. Radiograph of the left foot was reviewed and revealed no signs of osteomyelitis. There were radiographic signs of air and fluid lateral to the fifth metatarsophalangeal joint consistent with a soft tissue infection. Id. The doctor stated that after a thorough review of all available medical records and a physical examination of the Veteran, it was readily apparent that he had an infection on the lateral aspect of his left forefoot. This infection reached the level of the bone, however no osteomyelitis was evident on his preoperative radiographic tests. Dr. D.C. stated that it was with a reasonable degree of medical certainty that this infection would require a surgical debridement of the area and a bone biopsy to determine if there was infection involving the bone in this area. In the absence of infection of the bone, Dr. D.C. stated that he would recommend a soft tissue procedure only and no removal of bone or amputation. He noted that these infections often require several procedures to eradicate all of the infection and the patient may have needed a skin graft. Dr. D.C. stated that he would have attempted to save the none so that the patient could walk with a more normal gait. Id. Based on the foregoing evidence, the Board finds that entitlement to compensation under 38 U.S.C. § 1151 is not warranted for amputations of the left toes. The record indicates that the Veteran had a lengthy history of poorly controlled diabetes for which he was regularly treated by VA. For a month preceding his initial left toe amputation, the Veteran sought treatment at the VA podiatry clinic for ongoing issues with a left foot callus which developed into an ulcer. At each of these visits, the Veteran’s ulcer was examined and treated, including with the use of antibiotics. Further, the Veteran was educated about proper care of his left foot and he was informed of potential complications, up to and including amputation. When the Veteran presented to the VA medical center on February 23, 2014, he displayed multiple signs of infection to the left foot. VA treatment records, as discussed above, outline the specific symptoms which were suggestive of infection. As indicated by the Veteran’s own statement in July 2014, the need to amputate the 5th toe of the left foot was discussed with him, and he agreed to the procedure. Following a course of IV antibiotics and complications with the healing of his left foot, the Veteran underwent further resection of the left foot in July 2014. The Veteran’s essential contention is that radiological imaging at the time of his February 2014 amputation failed to show osteomyelitis, or bone infection, of the left toes, and that as such, amputation was unnecessary. He asserts that the amputation slowed his healing and created additional disability. Even affording the Veteran the benefit of the doubt that his February 2014 and July 2014 amputations resulted in additional disability, the evidence weighs against finding that the Veteran’s left toe amputations were proximately caused or aggravated by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA, or by an event not reasonably foreseeable. The Board finds the opinion of the March 2015 VA examiner to be highly persuasive and probative in this regard. The examiner's findings were based on a comprehensive review of the evidence and reflect consideration of the complete record and the Veteran's contentions. The examiner found the Veteran clearly had tissue infection and multiple signs of bone infection, as evidenced by positive tissue and bone cultures, systemic sepsis, non-viable necrotic tissue during surgery, cortical erosion, and lytic changes of bone as per the podiatrist interpretation of x-rays. The decision to remove the toe and partial metatarsal bone was made by the surgeons based on intra-operative findings, and the examiner indicated that such decision was clinically appropriate. The decision was further supported by findings of bone infection even after 6 weeks of IV antibiotics following surgery. The examiner stated that, given the Veteran’s history of poorly controlled diabetes, it would have been extremely difficult to control the infection with just antibiotics and wound debridement. Further, she noted that amputation in order to prevent the spread of infection to vital tissue is common in such case. The examiner concluded that there was no evidence that the Veteran’s toe amputation was caused or worsened by VA treatment due to carelessness, negligence, lack of skill or similar instance of fault. Further, the examiner stated that the Veteran’s toe amputation did not result from an event that could not have been reasonably foreseen by a reasonable health care provider. The opinion was supported with a thorough rationale which the Board finds to be consistent with the evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). The Board acknowledges the private opinion of Dr. D.C., submitted by the Veteran in September 2015. Although the Veteran asserts that this opinion supports his contention that his amputations were unnecessary, in fact, the opinion merely describes an alternative medical approach that could have been taken. Dr. D.C. acknowledges that it was readily apparent that the Veteran had an infection on the lateral aspect of his left forefoot, and that this infection reached the level of the bone, although there was no evidence of osteomyelitis on preoperative radiographic tests. Dr. D.C. further acknowledges that surgical debridement of the area was necessary and states that bone biopsy would be necessary to determine if there was infection involving the none in this area. Dr. D.C. states that in the absence of infection of the bone, he would have recommended a soft tissue procedure only and no removal of bone or amputation. He goes on to describe an alternative method of achieving this. Crucially, the opinion provided no indication that the measures taken by VA physicians were medically inappropriate. Additionally, while Dr. D.C. acknowledged that the infection reached the level of bone on the left foot, he did not address the multiple other signs of infection, both before and during the debridement procedure, that led VA physicians to make a clinical decision to perform the amputation. Thus, the Board finds the opinion of the March 2015 VA examiner to be more persuasive and of greater probative value. The Board has considered the statements made by the Veteran and acknowledges that he is competent to describe observable symptomatology and the sequences of certain events. However, the Veteran is not competent to provide an opinion as to the presence of bone infection, whether the amputation of his left toes was medically appropriate, or whether the VA medical personnel demonstrated carelessness, negligence, lack of proper skills, error in judgment or similar instance of fault. An opinion regarding the standard of care of the Veteran falls outside the realm of common knowledge of a lay person, that is, the opinion cannot be based on mere personal observation, which comes through sensory perception. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Such opinions require medical expertise and clinical training. Id. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and compensation under the provisions of 38 U.S.C. § 1151 is not warranted. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). 1. Entitlement to a compensable rating for service-connected bilateral hearing loss is remanded. The Veteran seeks entitlement to a compensable rating for bilateral hearing loss. Relevant to the Veteran's claim, the Court has held that, where the record does not adequately reveal the current state of a claimant's disabilities, fulfillment of the statutory duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the last examination. Allday v. Brown, 7 Vet. App. 517, 526 (1995). In this regard, the record reflects that the Veteran was most recently afforded a VA examination for his service-connected bilateral hearing loss in December 2014, almost four years ago. Additionally, the Board notes that the most recent VA treatment records appear to date from 2014. It is unclear if that was the last time the Veteran sought VA treatment, or if there are outstanding VA treatment records which have not been associated with the Veteran’s claims file. Thus, the Board finds that a contemporaneous VA examination is needed to fully and fairly evaluate the Veteran’s claim for a compensable disability rating. See Allday, supra; see also Caffrey v. Brown, 6 Vet. App. 377 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). Additionally, all updated VA and private treatment records should be obtained and associated with the claims file. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities is remanded. The Board finds that the issue of entitlement to a TDIU is inextricably intertwined with the Veteran's claim for a compensable rating for bilateral hearing loss. Specifically, any increased evaluation of the Veteran's service-connected bilateral hearing loss could impact the Veteran's claim of entitlement to a TDIU. See Harris v. Derwinski, 2 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). Therefore, adjudication of the claim for a TDIU rating must be deferred pending the aforementioned development. Accordingly, the matters are REMANDED for the following action: 1. Ask the Veteran to identify the provider(s) of any evaluations and/or treatment he has received for his bilateral hearing loss and to provide authorizations for VA to obtain records of any such private treatment. Obtain for the record complete clinical records of all pertinent evaluations or treatment (records of which are not already associated with the record) from the providers (VA and non-VA) identified. If any records sought are unavailable, the reason for their unavailability must be noted in the record. If a private provider does not respond to VA's request for identified records sought, the Veteran should be so notified, and reminded that ultimately it is his responsibility to ensure that private treatment records are received. 2. After all outstanding records have been associated with the record, the Veteran should be afforded an appropriate VA examination to determine the nature and severity of his service-connected bilateral hearing loss. All studies and tests should be performed and written interpretation should be associated with the examination report. The examiner should discuss any functional impact of the Veteran's service-connected bilateral hearing loss on his activities of daily living. (Continued on the next page)   3. After completion of the foregoing, and after undertaking any further development deemed warranted, readjudicate the Veteran’s claims, including the claim for entitlement to a TDIU. If the claims remain denied, furnish the Veteran and his representative a supplemental statement of the case and afford them an appropriate period of time to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Lewis