Citation Nr: 18154668 Decision Date: 12/03/18 Archive Date: 11/30/18 DOCKET NO. 16-47 911 DATE: December 3, 2018 ORDER Service connection for a neck (cervical) disability is denied. Service connection for bronchitis is denied. Service connection for chronic obstructive pulmonary disease (COPD) is denied. Service connection for obstructive sleep apnea (OSA) is denied. Service connection for hypertension is denied. Service connection for nerve damage of the hands and feet is denied. Service connection for an acquired psychiatric disorder is denied. Entitlement to a compensable disability evaluation since September 26, 2016, for bilateral hearing loss is denied. Entitlement to a disability rating in excess of 10 percent since April 28, 2014, for hepatitis C residuals is denied. Entitlement to an effective date earlier than September 26, 2016, for the grant of service connection for bilateral hearing loss is denied. Entitlement to an effective date earlier than April 28, 2014, for the grant of service connection for tinnitus and hepatitis C is denied. REMANDED The issue of service connection for a headache disorder is remanded. The issue of a disability rating in excess of 10 percent since April 28, 2014, for tinnitus is remanded. FINDINGS OF FACT 1. There is no probative medical evidence that indicates the Veteran’s current neck disability was incurred in service. 2. The probative medical evidence indicates the Veteran does not have a current bronchitis disability. 3. There is no probative medical evidence that indicates the Veteran’s current COPD disability was incurred in service. 4. There is no probative medical evidence that indicates the Veteran’s current OSA disability was incurred in service. 5. There is no probative medical evidence that indicates the Veteran demonstrated the onset of hypertension in service, or that his current hypertension was diagnosed within the presumptive period after discharge. 6. There is no probative medical evidence that indicates the Veteran’s current nerve damage to his hands or feet were caused or aggravated by a service-connected disability. 7. There is no probative medical evidence that indicates the Veteran’s current acquired psychiatric disabilities, to include anxiety and depression, were incurred in service or caused or aggravated by a service-connected disability. 8. Since September 26, 2016, the Veteran’s bilateral hearing loss disability manifested with 38 average pure tone decibel hearing loss and 100 percent speech discrimination for the right ear; and 40 average pure tone decibel hearing loss and 98 percent speech discrimination for the right ear. 9. Since April 28, 2014, the Veteran’s hepatitis C disability manifested with no more than intermittent right upper quadrant pain. 10. The Veteran filed a claim for bilateral hearing loss on September 26, 2016; the claim was ultimately granted, and the effective date is set to the date of claim. 11. The Veteran filed a claim for tinnitus and hepatitis C on April 28, 2014; the claims were ultimately granted and the effective date is set to the date of claim. CONCLUSIONS OF LAW 1. The criteria for service connection for a neck (cervical) disability have not been satisfied. 38 U.S.C. §§ 1131, 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306, 3.307, 3.309 (2017). 2. The criteria for service connection for bronchitis have not been satisfied. 38 U.S.C. §§ 1131, 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 3. The criteria for service connection for chronic obstructive pulmonary disease (COPD) have not been satisfied. 38 U.S.C. §§ 1131, 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 4. The criteria for service connection for obstructive sleep apnea (OSA) have not been satisfied. 38 U.S.C. §§ 1131, 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 5. The criteria for service connection for hypertension have not been satisfied. 38 U.S.C. §§ 1131, 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 6. The criteria for service connection for nerve damage of the hands and feet have not been satisfied. 38 U.S.C. §§ 1131, 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 7. The criteria for service connection for an acquired psychiatric disorder have not been satisfied. 38 U.S.C. §§ 1131, 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 8. Since September 26, 2016, the criteria for a compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.85, 4.86, 4.87a, DC 6100 (2017). 9. Since April 28, 2014, the criteria for a disability rating in excess of 10 percent for hepatitis C residuals have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.144, DC 7345 (2017). 10. The criteria for an effective date earlier than September 26, 2016, for the grant of service connection for bilateral hearing loss have not been met. 38 U.S.C. § 5110 (West 2014); 38 C.F.R. §§ 3.114, 3.400, 3.816 (2017). 11. The criteria for an effective date earlier than April 28, 2014, for the grant of service connection for tinnitus and hepatitis C have not been met. 38 U.S.C. § 5110 (West 2014); 38 C.F.R. §§ 3.114, 3.400, 3.816 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1976 to August 1977 and from August 1978 to October 1978. He was also discharged because of fraudulent entry, after being in military control from May 1981 to August 1981. Duty to Notify and Assist All necessary assistance to obtain evidence has been provided. As to the neck (cervical), COPD, and hypertension claims decided, there is no probative evidence suggesting the claimed conditions are related to service. Rather, only the Veteran’s general conclusory statement that his claimed disabilities are related to service is of record, which is insufficient to entitle a veteran to a medical examination under 38 U.S.C. § 5103A (d) (2) (B). Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (observing that “[s]ince all veterans could make such a statement, this theory would eliminate the carefully drafted statutory standards governing the provision of medical examinations and require the Secretary to provide such examinations as a matter of course in virtually every veteran’s disability case”). See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). VA has satisfied its duty to notify and assist and the Board may proceed with appellate review. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). “To establish a right to compensation for a present disability, a Veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’ - the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Certain disorders, listed as “chronic” in 38 C.F.R. § 3.309 (a) and 38 C.F.R. § 3.303 (b), are capable of service connection based on a continuity of symptomatology without respect to an established causal nexus to service. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Arthritis, such as degenerative joint disease, and hypertension, are both “chronic” diseases listed under 38 C.F.R. § 3.309 (a). Therefore, the presumptive service connection provisions based on “chronic” in-service symptoms and “continuous” post-service symptoms under 38 C.F.R. § 3.303 (b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. 38 C.F.R. § 3.303 (b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as arthritis or hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309 (a). While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. In deciding an appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination about the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran’s disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104 (a). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for a neck (cervical) disability Service treatment records (STRs) do not indicate any complaints, diagnoses or treatments for neck pain in service. The Veteran’s June 1977 and September 1978 reports of medical examination at separation indicates clinically normal musculoskeletal evaluations. Outpatient treatment reports in May 1992 indicated a radiographic study of the neck and cervical spine resulted in normal findings. May 2001 VA treatment records indicate the Veteran demonstrated lower cervical nerve root compression. In June 2011 x-rays showed significant cervical spine degenerative changes with a bulging disc. The preponderance of the evidence is against finding service connection for a neck disability. There is no probative medical evidence that indicates the Veteran’s current neck disability was incurred in service nor diagnosed within the presumptive period after discharge. Since the Veteran’s current neck disability was not incurred in service or diagnosed within the presumptive period, the claim for service connection is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Entitlement to service connection for bronchitis Service treatment records indicate the Veteran was treated for bronchitis in February 1977 and for an acute respiratory disease in August 1978. There are no other complaints, diagnoses or treatments for bronchitis, or any other respiratory symptoms, in service. The June 1977 and September 1978 reports of medical examination at discharge indicate clinically normal respiratory evaluations. VA treatment records do not indicate treatment for bronchitis. At the August 2016 VA medical examination for respiratory conditions, the Veteran reported annual symptoms similar to the symptoms he experienced in service, such as coughing and shortness of breath requiring oral antibiotics. The examiner noted a 1977 diagnosis of chronic bronchitis that was asymptomatic. A chest x-ray conducted during the examination revealed no active disease. The examiner opined that given the lack of treatment for bronchitis and the likelihood that the Veteran’s current respiratory symptoms were due to his underlying COPD disability, the Veteran’s current respiratory symptoms were less likely incurred in service. The preponderance of the evidence is against finding service connection for bronchitis. The probative medical evidence indicates the Veteran does not have a current bronchitis disability. Without a current disability, there can be no claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (“Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In absence of proof of a present disability there can be no valid claim.”) Since the Veteran does not have a current bronchitis disability, the claim for service connection is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 3. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) An April 2010 CT scan revealed mild COPD. STRs do not indicate any complaints, diagnoses, or treatments for COPD symptoms. The preponderance of the evidence is against finding service connection for COPD. There is no probative medical evidence that indicates the Veteran’s current COPD disability was incurred in service. Since the Veteran’s COPD disability was not incurred in service, the claim for service connection is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 4. Entitlement to service connection for obstructive sleep apnea (OSA) Obstructive sleep apnea (OSA) is a specific medical condition defined as the “cessation of breathing resulting from the collapse or obstruction of the airway with the inhibition of muscle tone that occurs during REM sleep.” See Dorland’s Illustrated Medical Dictionary 116-17 (32nd ed. 2012). VA treatment records indicate the Veteran was diagnosed with moderate OSA in November 2012. In January 1977, the Veteran complained of difficulty breathing and trouble sleeping. He was assessed with a bruised sternum and smoker’s cough. The Veteran’s June 1977 report of medical history at discharge indicates the Veteran reported insomnia, excessive nervousness, and frequent trouble sleeping. The examiner noted these symptoms were related to the Veteran’s recent drug possession charges. The Veteran denied frequent trouble sleeping on the September 1978 report of medical history at discharge. There are no complaints of OSA-related symptoms such as breathing stoppages while sleeping, loud snoring, or daytime fatigue during service. At the August 2016 VA medical examination, the Veteran reported loud snoring, waking up frequently at night, and dyspnea. The examiner opined that since the Veteran did not demonstrate OSA symptoms during service, his current disability was less likely incurred in service. The claim for service connection is denied. There is no probative medical evidence that indicates the Veteran’s current OSA disability was incurred in service. The Board notes the September 2016 medical opinion of a private physician who interviewed the Veteran and reviewed “medical records.” The physician opined the Veteran’s anxiety disorder contributed to and aggravated the Veteran’s OSA. This opinion is of low probative value. It does not substantiate the Veteran’s contention that his OSA disability was directly incurred in service. It raises another theory of entitlement, that of secondary service connection. However, since the Board will deny the Veteran’s claim for service connection for anxiety below, the Veteran’s claim for secondary service connection for his OSA disability is also denied. Since the Veteran’s OSA disability was not incurred in service or caused or aggravated by a service-connected disability, the claim for service connection is denied. 5. Entitlement to service connection for hypertension “Hypertension” refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 mm Hg systolic and 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic as reflective of hypertension. See Dorland's Illustrated Medical Dictionary, 896 (32nd ed. 2012). Similarly, for VA rating purposes, the term “hypertension” means that the diastolic blood pressure is predominantly 90 mm Hg or greater. The term “isolated systolic hypertension” means that the systolic blood pressure is predominantly 160 mm Hg or greater with a diastolic blood pressure of less than 90 mm Hg. See 38 C.F.R. § 4.104, DC 7101, Note (1). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. STRs indicate the Veteran demonstrated high blood pressure readings in June 1977 during an in-service bout with the flu. There are no other complaints, diagnoses, or treatments for high blood pressure or hypertension in service. The Veteran’s June 1977 report of medical examination at discharge indicates clinically normal heart and vascular evaluations, with a blood pressure reading of 112/78. The Veteran’s September 1978 report of medical examination at discharge indicates similar clinical evaluations, with a blood pressure reading of 112/62. VA treatment records indicate an examiner prescribed the Veteran hypertensive medication in December 2003. Although treatment records list hypertension as a current health problem, there is no confirmed diagnosis or other treatment for hypertension in the record. In September 2014, an examiner noted the Veteran demonstrated uncontrolled hypertension. The preponderance of the evidence is against finding service connection. There is no probative medical evidence that indicates the Veteran demonstrated the onset of hypertension in service, or that his current hypertension was diagnosed within the presumptive period after discharge. Since the Veteran’s hypertension disability was not incurred in service or diagnosed within the presumptive period, the claim for service connection is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 6. Entitlement to service connection for nerve damage of the hands and feet The Veteran contends the nerve damage to his hands and feet are secondary to his alcohol and drug addiction disability. Service personnel records indicate the Veteran was discharged from the military in June 1977 for willful misconduct due to possession of drug paraphernalia and drug abuse. Alcoholism or alcohol abuse is not a disability for VA compensation purposes. VA law and regulations preclude compensation for primary substance abuse disabilities and secondary disabilities that result from primary substance abuse as this is deemed to constitute willful misconduct on the part of the claimant. See 38 U.S.C. § 105 (a) (West 2014); 38 C.F.R. §§ 3.1 (m), 3.301 (d); see also Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001) (“the legislative history is quite clear that Congress intended to... preclude recovery for a primary alcohol abuse disability...”). Therefore, service connection for an alcohol abuse disability as a primary disability related to active duty service must be denied as a matter of law as service connection is not permissible for that type of disability. Treatment records show the Veteran was admitted to an in-patient drug and alcohol dependency treatment program in September 1981. The examiner noted the Veteran was “tremulous” during the mental status examination but that the Veteran’s nervousness settled with treatment. June 2014 VA treatment records indicate an examiner opined the Veteran’s hand tremors were “likely” related to his prior history of severe alcohol dependence and that they are unlikely related to the Veteran’s psychiatric medications. At the August 2016 VA medical examination for central nervous system conditions, the Veteran reported he did not recall the onset of hand tremors. The examiner diagnosed the Veteran with bilateral hand tremors and opined that since the Veteran did not demonstrate hand tremors in service, the Veteran’s current hand tremors were not incurred in service. The examiner did not diagnose the Veteran with feet tremors. The Veteran does not allege direct service connection for nerve damage to his hands and feet, nor does the record raise this theory of entitlement. Since the Board must deny the Veteran’s claim for service connection for alcohol and drug addiction, the Veteran’s claim for secondary service connection for nerve damage to the hands and feet is also denied. 7. Entitlement to service connection for an acquired psychiatric disorder The Veteran underwent counseling for his drug and alcohol addiction during service in May 1977 to June 1977. During the program, the Veteran was found with drug paraphernalia, culminating in separation for drug abuse. At the June 1977 mental status examination at separation, the Veteran demonstrated “no significant mental illness.” At the June 1977 report of medical history at discharge, the Veteran reported insomnia and excessively nervous; frequent trouble sleeping; depression or excessive worry; and nervous trouble. The examiner noted that the Veteran’s nervousness and other reported symptoms were related to the Veteran’s recent drug possession charge. His June 1977 clinical psychiatric evaluation was normal. At his July 1978 reenlistment examination, the Veteran’s clinical psychiatric evaluation was normal. The Veteran denied nervous trouble, depression, and worry on his July 1978 report of medical history. In August 1978, the Veteran admitted to fraudulently reenlisting in the military for failing to report his prior discharge for drug abuse and possession. At his September 1978 mental status examination at discharge, the examiner noted no significant mental illness, and the Veteran denied depression, excessive worry and nervous trouble of any sort on his September 1978 report of medical history. His clinical psychiatric evaluation at discharge was normal. VA treatment records indicate the Veteran was diagnosed with generalized anxiety disorder in April 2006 and September 2009, major depression in March 2010, and unspecified mood and anxiety disorders in 2014. At the January 2016 examination by a private psychologist, the examiner diagnosed the Veteran with unspecified anxiety disorder. The Veteran reported he was socially isolated and withdrawn. The examiner opined the Veteran’s current unspecified anxiety disorder more likely than not began in service, has continued uninterrupted to the present, and was aggravated by his service-connected tinnitus and hepatitis C disability. The examiner noted literature that supported the contention that military service impacts depression, anxiety and quality of life satisfaction, and that there was a correlation between depression, anxiety and ongoing medical conditions. This opinion is conclusory and of low probative value. See Stefl v. Nicholson, 21 Vet. App. 120, 124-125 (2007) (holding that “a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to a doctor’s opinion”). The examiner did not provide a fact-based explanation for her conclusions linking the Veteran’s current psychiatric diagnosis to his service. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). At the August 2016 VA medical examination for mental disorders, the examiner diagnosed the Veteran with unspecified depressive disorder, noting the Veteran demonstrated overlapping symptoms of unspecified mood disorder. The examiner noted the October 1981 VA examiner’s discharge summary from the alcohol and drug dependency treatment program that the Veteran demonstrated “no abnormal psychiatric features” other than mild anxiety because he was going home. The examiner opined that the Veteran’s current psychiatric diagnoses were therefore not incurred in service. At the November 2016 VA medical examination for mental disorders, the Veteran reported using drugs and alcohol in service in order to obtain a discharge. He reported current symptoms of continuous depression and anxiety. The examiner diagnosed the Veteran with unspecified anxiety disorder and mild recurrent major depressive disorder. The examiner also noted alcohol use disorder, amphetamine use disorder, and opioid use disorder, all in full remission per the Veteran’s report. The examiner reviewed the Veteran’s entire claims file, including the private January 2016 mental disorders examination, and opined the Veteran’s mental health conditions were less likely than not aggravated by his service-connected tinnitus and hepatitis C disabilities. The examiner reviewed the literature cited by the January 2016 private examiner and opined the literature did not support a causal link between tinnitus and mental health symptoms. In addition, the November 2016 examiner noted the Veteran’s anxiety was “vague” in description and inconsistent with a diagnosis of anxiety due to a general medical condition such as hepatitis C or tinnitus. Finally, the examiner noted the Veteran’s responses during the November 2016 examination did not suggest a link between his service-connected disabilities and his mental disorders. For example, the examiner noted during the 30-minute diagnostic interview, the Veteran did not spontaneously indicate that his current depression or anxiety was related to his service-connected disabilities. The examiner summarized that it was less likely than not that the Veteran’s service-connected disabilities exacerbated his anxiety or depression beyond their natural progression. The preponderance of the evidence is against finding service connection for anxiety or depression. There is no probative medical evidence that indicates the Veteran’s current psychiatric diagnoses are related to service, or aggravated beyond their natural progression by the Veteran’s service-connected disabilities. Since the Veteran’s current psychiatric diagnoses were not incurred in service or caused or aggravated by a service-connected disability, the claim for service connection is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Increased Rating Disability ratings are determined by applying criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.” See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). Additionally, the evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104 (a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In assigning a higher disability rating, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 8. Entitlement to a compensable disability evaluation since September 26, 2016, for bilateral hearing loss The Rating Schedule provides rating tables for the evaluation of hearing impairment. Table VI assigns a Roman numeral designation (I through XI) for hearing impairment based on the pure tone threshold average and controlled speech discrimination (Maryland CNC) testing. Table VIa assigns a Roman numeral designation for hearing impairment based only on the pure tone threshold average, and is used when speech discrimination testing is not appropriate or when indicated under the provisions of 38 C.F.R. § 4.86, which relate to exceptional patterns of hearing impairment. The “pure tone threshold average” is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. 38 C.F.R. § 4.85 (d). Table VII is used to determine the rating assigned by combining the Roman numeral designations for hearing impairment of each ear. 38 C.F.R. § 4.85 (e). Exceptional patterns of hearing impairment are provided for in 38 C.F.R. § 4.86. When the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear is evaluated separately. 38 C.F.R. § 4.86 (a). Ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). However, in addition to providing objective test results, a VA audiological examination report must address the functional effects caused by a hearing disability because an extraschedular rating under 38 C.F.R. § 3.321 (b) “does not rely exclusively on objective test results to determine whether a referral for an extraschedular rating is warranted.” Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). VA’s policy requiring VA audiologists to describe the effect of a hearing disability on occupational functioning and daily activities facilitates extraschedular determinations. Id. The Veteran underwent one audiological evaluation during the appellate period. At the August 2016 VA audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 35 25 35 55 LEFT 25 30 35 30 65 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 98 in the left ear using the Maryland CNC speech discrimination test. The average pure tone thresholds of 1000, 2000, 3000, and 4000 Hz, rounded to the nearest whole number, were 38 for the right ear and 40 for the left ear. He was assessed with bilateral sensorineural hearing loss. The examiner noted the functional effects of the Veteran’s hearing loss included difficulty hearing in noisy environments. The evidence does not support a finding of “exceptional” hearing loss in the current case. Specifically, the defined regulatory “exceptional” patterns (pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz) are not found in this case. See 38 C.F.R. § 4.86. As “exceptional” hearing loss does not exist, it is necessary to apply the criteria found in 38 C.F.R. 4.87 at Table VI to the Veteran’s audiological examinations of record. With regards to the August 2016 examination, the results yield a numerical designation of I for both ears (between 0 and 41 average pure tone decibel hearing loss, with between 92 and 100 percent speech discrimination). Entering the category designations for each ear into Table VII results in a noncompensable disability evaluation. The preponderance of the evidence is against finding a compensable rating for the Veteran’s hearing loss since September 26, 2016. The Veteran’s bilateral hearing loss disability manifested with 38 average pure tone decibel hearing loss and 100 percent speech discrimination for the right ear; and 40 average pure tone decibel hearing loss and 98 percent speech discrimination for the right ear. The results of the examination are probative and valid for rating purposes, and reflect the severity of the Veteran’s bilateral hearing loss at the time. The Veteran is competent to describe the effects of his hearing loss on his daily functioning, such as having difficulty understanding other people with background noise present. However, disability ratings are derived by a mechanical application of the rating schedule. Lendenmann, 3 Vet. App. at 349. Thus, the Board has no discretion in this matter and must predicate its determination based on the results of the audiological examinations of record. Mechanical application of the Rating Schedule to the audiometric findings establishes a noncompensable rating since September 26, 2016. Given these facts, the Board finds that a noncompensable evaluation since September 26, 2016, adequately reflects the Veteran’s bilateral hearing loss disability. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 9. Entitlement to a disability rating in excess of 10 percent since April 28, 2014, for hepatitis C residuals The Veteran’s hepatitis C is rated 10 percent disabling under the schedule of ratings for the digestive system. 38 C.F.R. § 4.144, DC 7354. DC 7345 provides for a noncompensable rating for non-symptomatic hepatitis. A 10 percent rating is warranted for intermittent fatigue, malaise, and anorexia, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period. A 20 percent rating is warranted for daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. A 40 percent rating is warranted for daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. A 60 percent rating is warranted for daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly. A 100 percent rating is warranted for near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). According to Note 2 of DC 7345, an “incapacitating episode” is a period of acute signs and symptoms that require bed rest and treatment by a physician. At the September 2014 VA medical examination, the Veteran reported intermittent right upper quadrant pain with no incapacitating episodes. The examiner noted a soft abdomen with no enlarged organs. Lab results confirmed the presence of hepatitis C with spontaneous clearing of the viral load. VA treatment records do not indicate any treatment for hepatitis C residuals. A March 2016 VA examiner noted the Veteran’s recent liver enzymes were normal. Since April 28, 2014, the Veteran’s hepatitis C disability manifested with no more than intermittent right upper quadrant pain and warrants a 10 percent rating. A higher rating is not warranted because the Veteran’s disability did not demonstrate with daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. Given these facts, the Board finds that a 10 percent evaluation since April 28, 2014, adequately reflects the Veteran’s hepatitis C disability. 38 C.F.R. § 4.7. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Effective Date Generally, the effective date for a grant of service connection and disability compensation is the day following separation from active military service or the date entitlement arose if the claim is received within one year after separation from service; otherwise, the effective date will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 10. Entitlement to an effective date earlier than September 26, 2016, for the grant of service connection for bilateral hearing loss During the Veteran’s August 2016 VA medical examination for hearing impairment, the examiner noted the Veteran’s hearing demonstrated sensorineural hearing loss in both ears. The RO advised the Veteran in a September 2016 correspondence that he may be entitled to compensation and that he must submit his claim on a standardized form to initiate a claim for benefits. The Veteran filed a claim for bilateral hearing loss on September 26,2016. The Veteran contends he is entitled to an earlier effective date because the VA medical examination that diagnosed the disability occurred on August 19, 2016. VA regulation 38 C.F.R. § 3.1 (p) requires all claims to be in writing. In addition, for purposes of establishing the requirements and procedures for seeking veterans’ benefits, the United States Court of Appeals for the Federal Circuit (Federal Circuit) pointed out that a claim, whether “formal” or “informal,” must be “in writing” in order to be considered a “claim” or an “application” for benefits, and that the provisions of 38 C.F.R. §3.1 (p) define “claim,” informal as well as formal, as a “communication in writing.” Further, the Federal Circuit stated that when 38 C.F.R. § 3.155 (a) refers to “an informal claim,” it necessarily incorporates the definition of that term in 38 C.F.R. § 3.1 (p) as a “communication in writing.” Rodriguez v. West, 189 F.3d 1351 (Fed. Cir. 1999). In addition, medical evidence reflecting treatment for and diagnosis of a condition does not constitute, by itself, an informal original claim for service connection under 38 C.F.R. § 3.155 (a), “because the mere presence of the medical evidence does not establish an intent on the part of the veteran to seek” service connection for that condition. MacPhee v. Nicholson, 459 F.3d 1323, 1326 (Fed. Cir. 2006). Informal claims were discontinued after March 24, 2015. As the Veteran did not submit the claim within one year of discharge from service, VA regulations provide that the effective date is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. Since the Veteran submitted his claim on September 26, 2016, entitlement to an effective date earlier than September 26, 2016, for bilateral hearing loss is denied. 11. Entitlement to an effective date earlier than April 28, 2014, for the grant of service connection for tinnitus and hepatitis C residuals The Veteran’s VA Form 21-526EZ Application for Disability Compensation for hepatitis C and tinnitus, among other claimed conditions, was received on April 28, 2014. There is no evidence of a claim prior to that date. As the Veteran did not submit the claims within one year of discharge from service, VA regulations provide that the effective date is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. Since the Veteran submitted his claim on April 28, 2014, entitlement to an effective date earlier than April 28, 2014, for tinnitus and hepatitis C is denied. REASONS FOR REMAND 1. Entitlement to service connection for a headache disorder is remanded. With regards to the Veteran’s claim for entitlement to service connection for a headache disorder, the August 2016 VA medical opinion is inadequate to resolve the appeal. The examiner did not opine if the Veteran’s service-connected tinnitus disability caused or aggravated the Veteran’s current migraine headache disability. 2. Entitlement to a disability rating in excess of 10 percent since April 28, 2014, for tinnitus is remanded. Veteran has been in receipt of a 10 percent rating for tinnitus since April 28, 2014. This is the maximum schedular rating available. See 38 C.F.R. § 4.87, DC 6260. In an exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director of the Compensation and Pension Service, upon field station submission, is authorized to approve based on the criteria set forth in this paragraph an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability. The governing norm in exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321 (b) (1). See Thun v. Peake, 22 Vet. App. 111 (2008). Since the Board must remand the Veteran’s service connection claim for a headache disorder, the Board must also remand the claim for a rating in excess of 10 percent for the Veteran’s tinnitus because it is inextricably intertwined with the issue of whether the Veteran’s tinnitus disability presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); see also Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). The matters are REMANDED for the following action: 1. Obtain any outstanding VA medical records and associate them with the claims file. 2. Return the claims file to the August 2016 VA examiner and request s/he re-review the claims file and respond to the inquiries below. If the examiner is not available, arrange for another appropriate VA examiner to provide an addendum medical opinion to assist in determining the relationship between the Veteran’s current migraine headache disorder and his service-connected tinnitus disability. All appropriate tests, studies and consultations should be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. A rationale should be given for all opinions and conclusions rendered. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinions: a) Is the Veteran’s migraine headache disorder proximately due to or aggravated (e.g. worsened, and if so, to what degree) by the Veteran’s service-connected tinnitus disability? b) If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. The examiner must review the entire record in conjunction with rendering the requested opinions. IN ADDITION TO ANY RECORDS THAT ARE GENERATED BECAUSE OF THIS REMAND, the VA examiner’s attention is drawn to the following: * March 2016 neurology consult notes, when the examiner assessed the Veteran with chronic headache syndrome, and noted the Veteran demonstrated migraines without aura; cervicogenic headaches; medication overuse headaches; with a contributing factor of sleep apnea. See “CAPRI,” received March 29, 2017, pages 10-11 of 20. * The August 2016 headache disability benefits questionnaire, when the Veteran reported tinnitus prior to the onset of headaches, and the examiner diagnosed the Veteran with migraine headaches. See “C&P Exam,” received August 19, 2016, pages 1-3 of 67. * The September 2016 headache disability benefits questionnaire, when the examiner opined the Veteran’s headaches are caused by his service-connected tinnitus disability. See “VA Examination,” received September 26, 2016, pages 1-3 of 17. * The October 2016 addendum medical opinion, when the examiner noted that the Veteran demonstrated tension headaches in service, and that medical literature did not support the contention that tinnitus was associated with tension headaches. The examiner also noted that migraine headaches are known to be associated with tinnitus. See “C&P Exam,” received October 20, 2016. 3. Following the review and any additional development deemed necessary, re-adjudicate the claims. Should the claims not be granted in its entirety, issue an appropriate supplemental statement of the case (SSOC) and forward the claims to the Board for adjudication. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (Continued on the next page)   This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Anwar, Associate Counsel