Citation Nr: 18155155 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 15-20 850 DATE: December 4, 2018 ORDER Entitlement to service connection for a bladder disability is dismissed. Entitlement to service connection for degenerative disc disease of the lumbar spine, residual of injury, is granted. Entitlement to service connection for chronic headaches, residual of injury, is granted. Entitlement to service connection for residuals of left knee injury, now status post left total knee replacement, is granted. Entitlement to compensation under 38 U.S.C. § 1151 for prescription of Piroxicam by VA causing truncal vagotomy (claimed as stomach surgery) is denied. Entitlement to a compensable disability rating for left testicular spermatoceles is denied. Entitlement to a compensable disability rating for scars of the left thigh post shrapnel wounds is denied. Entitlement to a compensable disability rating for bilateral tinea pedis is denied. REMANDED Entitlement to service connection for a bilateral foot disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for right leg sciatica, to include as secondary to service-connected degenerative disc disease of the lumbar spine is remanded. Entitlement to a disability rating in excess of 20 percent for degenerative joint disease of the left shoulder with residuals scars is remanded. Entitlement to a disability rating in excess of 10 percent for degenerative joint disease of the right wrist status post right wrist fracture is remanded. Entitlement to a disability rating in excess of 10 percent for residuals of right thumb fracture is remanded. Entitlement to a disability rating in excess of 30 percent for recurrent major depressive disorder is remanded. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU) is remanded. Entitlement to secondary service connection for prescription of Piroxicam by VA causing truncal vagotomy (claimed as stomach surgery) is remanded FINDINGS OF FACT 1. During the March 2018 Board hearing, the Veteran withdrew his appeal concerning the issue of entitlement to service connection for a bladder disability. 2. A residuals of back injury, diagnosed as degenerative disc disease of the lumbar spine had its onset in service. 3. A left knee injury diagnosed now as status post left total knee replacement is attributable to service. 4. Chronic headaches are attributable to in service injury. 5. Additional disability of gastritis and peptic ulcer disease resulting in truncal vagotomy in May 2009 was not the result of carelessness, negligence, lack of proper skill, error in judgment or other instance of fault on the part of VA, nor was it due to an event not reasonably foreseeable. 6. The Veteran’s left testicular spermatoceles disability has been manifested by left testicular pain and discomfort with instances of tenderness to palpation, but the disability has not manifested in long-term drug therapy, hospitalizations, or intermittent intensive management, or displayed urinary symptoms, impairment of the Veteran’s renal function, tubular infection, infectious disease, immune disorder, nutritional deficiency, complete testicular atrophy, or alteration of consistency of his left testicle. 7. The Veteran’s tinea pedis affects less than five percent of his total body area and his exposed areas, and has not been treated with systemic therapy such as corticosteroids or other immunosuppressive drugs. 8. The Veteran’s scars of the left thigh status post shrapnel wounds are manifested by three scars that are stable, superficial, do not measure at least 6 square inches (39 sq. cm.), have not limited function, and are not painful. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal of the issue of entitlement to service connection for a bladder disability have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. Residual of lumbar spine injury was incurred in wartime service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 3. Residual of left knee injury, now, status post left total knee replacement was incurred in wartime service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 4. Chronic headaches, residual of injury, were incurred in wartime service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 5. The criteria for compensation pursuant to the provisions of 38 U.S.C. § 1151 for prescription of Piroxicam by VA causing truncal vagotomy (claimed as stomach surgery) have not been met. 38 U.S.C. §§ 1151, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.361 (2017). 6. The criteria for a compensable rating for left testicular spermatoceles have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.115b, Diagnostic Codes 7599-7525. 7. The criteria for a compensable disability rating for tinea pedis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.118, Diagnostic Codes 7813-7806 (2017). 8. The criteria for a compensable disability rating for scars of the left thigh status post shrapnel wounds have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7805 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1968 to June 1977. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In March 2018, the Veteran testified at a videoconference hearing held at the RO before the undersigned Veterans Law Judge (VLJ) with regard to the issues of entitlement to TDIU and entitlement to increased ratings for recurrent major depressive disorder, degenerative joint disease of the left shoulder with residual scars, degenerative joint disease of the right wrist status post right wrist fracture, residual of right thumb fracture, and scars of the left thigh. He also presented testimony as to the issues of service connection for a lumbar spine disability, cervical spine disability, and left knee disability. The Veteran did not request testimony as to the remaining issues on appeal. A transcript of the hearing is associated with the record. During the March 2018 Board hearing, the VLJ clarified the issues on appeal; clarified the concept of service connection, increased rating, and TDIU claims; identified potential evidentiary defects which included the severity of the Veteran’s right wrist, major depressive disorder, right thumb, left shoulder, and scar disabilities as well as a nexus between the Veteran’s lumbar spine, cervical spine, and left knee disabilities and service; clarified the type of evidence that would support the Veteran’s claims; enquired as to the existence of potential outstanding records; and held the record open for 60 days for the submission of additional evidence. Thus, the actions of the VLJ supplement the VCAA and comply with any related duties owed during a hearing set forth in 38 C.F.R. § 3.103. Additional VA treatment records were associated with the claims file following the final adjudication of the claims by the RO (April 2015 statement of the case). Although the Veteran has not waived initial review of this evidence pursuant to 38 C.F.R. § 20.1304 (2017), the Board notes that these records are not relevant to the claims denied herein. Moreover, while these records document treatment for the Veteran’s left knee and headaches, as will be discussed below, the Board is granting these claims. Service Connection Bladder disability An appeal may be withdrawn in writing as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2017). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. During the March 2018 Board hearing, the Veteran explicitly, unambiguously, and with a full understanding of the consequences, withdrew the issue of service connection for a bladder disability. The undersigned clearly identified the issue on appeal and that the claim was not on appeal and withdrawn. Moreover, the Veteran affirmed that he was requesting a withdrawal as to the appeal. See the March 2018 Board hearing transcript, page 2. The Veteran’s full understanding of the consequences are shown based on his affirmation that the claim was withdrawn and no longer on appeal. See Acree v. O’Rourke, 891 F.3d 1009 (Fed. Cir. 2018). Thus, the Board finds there remains no allegation of errors of fact or law for appellate consideration concerning these issues. Accordingly, the Board does not have jurisdiction to review the appeal as to this issue, and it is dismissed. Pertinent legal criteria Veterans are entitled to compensation from VA if they develop a disability “resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty.” 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). For certain chronic disease, including arthritis, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. 3.303(b). Lumbar spine disability, left knee disability, and chronic headaches The Veteran contends that he has a lumbar spine disability as well as chronic headaches related to service, in particular from a hard landing in a helicopter during his combat service in Vietnam while performing his duties as a pilot. See, e.g., the March 2018 Board hearing transcript, page 13. He also contends that he has a left knee disability that is related to service, in particular from an injury in November 1973 during service in Korea when he attempted to get into his helicopter and slipped on ice. See, e.g., a private treatment record from J.H., M.D. dated March 2018. Although the Veteran’s available service treatment records do not document treatment for the back, left knee, or headaches, the Board acknowledges his report that he was injured in service from performing duties as a helicopter pilot during combat service in Vietnam as well as his service in Korea. The Board further notes that the Veteran is in receipt of the Purple Heart for his combat service in Vietnam. Under 38 U.S.C. § 1154(b), a combat veteran’s assertions of an event during combat are to be presumed if they are consistent with the time, place and circumstances of such service. Also, G.W., who served with the Veteran, documented the Veteran’s knee injury during service in Korea. The Board also notes that the Veteran’s personnel records document his military occupational specialty (MOS) as a pilot. In light of the circumstances of the Veteran’s service, the Board accepts his description of in-service events in which he had injury to his head, back, and left knee from performing his duties as a pilot. As will be discussed below, the Board finds that the most probative evidence of record demonstrates that the Veteran currently has degenerative disc disease of the lumbar spine, status post left total knee replacement with degenerative joint disease, and chronic headaches that manifested during his active duty. A probative medical opinion is of record concerning the issue of nexus for the Veteran’s lumbar spine, left knee, and headaches disabilities in the form of a March 2018 private opinion by Dr. J.H. Specifically, Dr. J.H. provided examinations of the Veteran in September 2017 and January 2018 and documented review of the Veteran’s medical history as well as the Veteran’s in-service injury from his pilot duties and hard landing during combat service and report of back, left knee, and headaches symptoms related to the injuries. After examination of the Veteran and consideration of the Veteran’s medical history, Dr. J.H. concluded that the Veteran has degenerative disc disease of the lumbar spine related to the reported in-service injury. His rationale was based on his finding that the injury initiated traumatic compression to the Veteran’s and the compression accelerated the process of degeneration of the lumbar spine discs. Also, Dr. J.H. concluded that it is more likely than not that the Veteran currently has chronic headaches which are related to the same in-service injury. His rationale was based on his finding that the Veteran hit his nose very hard with his right hand when he landed, causing injury to his nose, right eyebrow, and nasal septum which resulted in continuous headaches. Finally, Dr. J.H. opined that the Veteran has status post left total knee replacement with degenerative joint disease that is related to service on the basis that the Veteran had continuous left knee pain and a limp following the in-service injury from slipping on ice as he attempted to board his helicopter and that those symptoms are congruent with the current symptoms. In this case, the Board finds that the most probative evidence supports a finding that the Veteran currently has degenerative disc disease of the lumbar spine, status post left total knee replacement with degenerative joint disease, and chronic headaches that had its onset during the Veteran’s service. In this regard, the Board finds the March 2018 private medical opinion of Dr. J.H. to be of great probative value as the opinion was based on a thorough consideration of the Veteran’s medical history. Notably, there is no medical opinion of record which indicates that the Veteran’s degenerative disc disease of the lumbar spine, status post left total knee replacement with degenerative joint disease, and chronic headaches did not have its onset in service. Accordingly, there is a competent and credible basis to conclude that the Veteran’s current degenerative disc disease of the lumbar spine, status post left total knee replacement with degenerative joint disease, and chronic headaches are caused by active wartime duty. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). Therefore, service connection for degenerative disc disease of the lumbar spine, status post left total knee replacement with degenerative joint disease, and chronic headaches is warranted. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. § 1151 A Veteran may be awarded compensation for additional disability, not the result of his willful misconduct, if the disability was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by VA, either by a VA employee or in a VA facility as defined in 38 U.S.C. § 1701(3)(A), and the proximate cause of the disability was (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination, or (2) an event not reasonably foreseeable. 38 U.S.C. § 1151; 38 C.F.R. § 3.361. VA treatment records include an operative reported dated May 2009 which indicated that the Veteran had a gastric outlet obstruction secondary to peptic ulcer disease. The operation consisted of an exploratory laparotomy, truncal vagotomy, gastroenterostomy isoperistaltic antecolic, and an enteroenterostomy. A final survey was performed. There was noted to be no bleeding at the esophageal hiatus. The abdomen was then closed. Both posterior and anterior sheaths were closed. The subcutaneous tissue was irrigated and the skin was closed with staples. VA outpatient treatment records note a few complaints of nausea secondary to the surgery/gastroparesis. It was recommended that the Veteran eat small frequent meals with low fiber and low fat and to drink a diet coke between meals. In an October 2009 statement, the Veteran essentially contended that the May 2009 surgery was the result of negligent care provided by VA. Specifically, the Veteran contends that prior to the surgery, he was prescribed Piroxicam for orthopedic treatment by VA that caused gastric problems and resulted in the May 2009 surgery. VA treatment records document prescription of Piroxicam in November 2008 for knee and back pain. Although a February 2009 record noted the Veteran should stop taking Piroxicam, he continued to take it until the beginning of May 2009. A private treatment record dated March 2018 from Dr. J.H. indicates that the Veteran developed gastritis and peptic ulcer disease due to taking Piroxicam and required the May 2009 surgery due to such. The Board must first address whether the May 2009 surgery caused additional disability. To establish causation, the evidence must show that the hospital care, medical or surgical treatment or examination resulted in the Veteran’s additional disability or death. Merely showing that a Veteran received care, treatment or examination and that the Veteran has an additional disability or died does not establish cause. 38 C.F.R. § 3.361(c)(1). The Board finds that the Veteran developed gastritis and peptic ulcer disease as a result of taking Piroxicam. The Board finds the report of Dr. J.H. indicating such to be of probative value. Therefore, the Board will address whether the proximate cause of the Veteran’s gastritis and peptic ulcer disease resulting in the May 2009 surgery was due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA or an event not reasonably foreseeable. In a VA opinion report dated September 2010, the examiner noted the Veteran’s past medical history, surgeries, and extensive list of prescribed medications which included Piroxicam from the end of 2008 to beginning of May 2009. The examiner also detailed the history of gastrointestinal complaints beginning in April 2009, the surgery in May 2009 for gastric outlet obstruction and the follow up care. The examiner reported the Veteran did well postoperatively. The examiner further acknowledged the recent Canadian equivalent of the Food and Drug Administration has issued a statement indicating warning against the use of Piroxicam for short-term treatment of acute and short-term conditions causing pain and inflammation. He therefore indicated that the effects of Piroxicam were reasonably foreseeable. However, the examiner further noted the Veteran had multiple problems of a chronic nature, and would fall within the category of utilization of this medication for chronic arthritic conditions including rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis. As such, the medication used would be considered reasonable in the Veteran’s case. Additionally, the examiner commented that as far as the treatment of the Veteran by VA is concerned and the allegations of negligence, after his review of the records, the examiner determined the Veteran had appropriate care. The examiner stated the Veteran’s duration of symptoms was fairly short and he was diagnosed promptly and given a trial of non-operative (conservative) management which would be standard practice. The examiner also reported the Veteran was not completely obstructed and was able to keep food down and that he did improve following his non-operative management, but that given the degree of obstruction, operative intervention was reasonable. The examiner reported this was also in agreement with the recommendations to rapidly address the acid production in such patients and that this is what was done by VA in the Veteran’s care. Moreover, the examiner reported the Veteran’s operation was performed in a timely fashion and noted he was only in the hospital 6 days and that he did well afterwards and his symptoms resolved. The examiner stated this was a good result from a surgical standpoint in terms of both prompt diagnosis and appropriate timely treatment. There are no contrary medical opinions of record. Although Dr. J.H. noted in the March 2018 private opinion that the Veteran’s use of Piroxicam caused the gastritis and peptic ulcer disease, he did not state that such was due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA or an event not reasonably foreseeable. The Board must assess the credibility and weight to be given the evidence. The 2010 VA opinion is credible and deserving of significant probative weight. It is based on a thorough discussion of the Veteran’s history and demonstrates the surgeon’s substantial knowledge and skill in analyzing the data, relevant factors noted in Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The VA examiner explained why VA met the usual standard of care and why the care was not the primary inciting cause of the Veteran’s gastric problems. This is the most persuasive evidence on the question of whether there is additional disability due to prescription of Piroxicam and the May 2009 surgery, and it weighs against the claim. Simply put, the record contains no reliable evidence which tends to substantiate the Veteran’s contentions that he suffered additional disability due the VA care he received that was due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA or an event not reasonably foreseeable. The Veteran is not competent to assert such because an opinion as to this would involve analysis of medical reports and the standard of care at that time. Also, determinations as to whether a physician’s diagnosis, treatment or procedures for arriving at a diagnosis or course of treatment conform to ordinary standards of medical care generally present matters outside the ordinary knowledge of laypersons and therefore must be shown by medical evidence. See OGCPREC 05-01. The Board finds that this is the case in this claim. Accordingly, the most probative evidence in this case is the 2010 VA opinion, which reflects that there was not additional disability that was the result of carelessness, negligence, lack of proper skill, error in judgment or other instance of fault on the part of VA, or was it due to an event not reasonably foreseeable. The Board is aware that the Veteran is competent to relate that which he has been told by an examiner. We conclude that the actual records are far more probative and far more credible than the lay recounting. Although some of the lay statements may fall within the realm of competence, such statements are outweighed by the reasoned and comprehensive medical opinion evidence. Notably, the Veteran has never argued that he was treated without informed consent. 38 C.F.R. § 3.361(d)(1)(ii). The record does not otherwise reflect that the Veteran was unable to provide informed consent. Accordingly, the Board finds that benefits are not warranted on this basis. For the foregoing reasons, the preponderance of the evidence is against the claim for compensation under the provisions of 38 U.S.C. § 1151 for additional disability as a result of prescription of Piroxicam causing a truncal vagotomy performed at a VA medical facility in May 2009. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C. § 5107(b). Increased ratings Pertinent legal criteria Disability evaluations are determined by comparing a Veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2017). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 4.3 (2017). When a disability has undergone varying and distinct levels of severity during the appeal, it is appropriate to apply staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Left testicular spermatoceles Service connection for left testicular spermatoceles was granted in a July 2010 rating decision, and is rated noncompensable under Diagnostic Codes 7599-7525. A condition without a Diagnostic Code, such as left testicular spermatoceles, may be rated under a closely related disease or injury in which not only the functions affected but the anatomical localization and symptomatology are closely analogous. See 38 C.F.R. § 4.20. The Board notes that a May 2010 VA examination reflects that the Veteran had a history of thickening of the epididymis on the left and that he currently has a left spermatocele. Accordingly, the Veteran’s service-connected left testicular spermatocele is properly evaluated by analogy under Diagnostic Code 7525, chronic epididymo-orchitis. Diagnostic Code 7525 provides that chronic epididymo-orchitis shall be rated under the criteria for urinary tract infection, or, for tubular infections, it should be rated according to 38 C.F.R. § 4.88b (infectious diseases, immune disorders, and nutritional deficiencies) or 38 C.F.R. § 4.89 (ratings for inactive nonpulmonary tuberculosis in effect on August 19, 1968), whichever is appropriate. See 38 C.F.R. § 4.115b, Diagnostic Code 7525. The rating criteria for urinary tract infection provides that a 10 percent rating is warranted if the condition requires long-term drug therapy, 1-2 hospitalizations per year, and/or intermittent intensive management. A 30 percent rating is warranted if the condition is manifested by recurrent symptomatic infection requiring drainage and/or frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. Higher ratings may also be assigned for poor renal function under the criteria for renal dysfunction. 38 C.F.R. § 4.115a. The Veteran was provided a VA examination in May 2010. He reported intermittent pain in the left testicle and that multiple cysts developed in the testicle. The cysts were drained several months previously with temporary relief of pain, but the cysts recurred. He underwent a nerve block to the scrotum a few months previously with moderate relief of pain. The VA examiner did not report any history of genitourinary malignancy. Although the Veteran self-catheterized, this was due to his benign prostatic hypertrophy and neurogenic bladder. There were no findings of lethargy, weakness, anorexia, or weight change. There were no urinary symptoms noted or effect on daily activities. A testicular examination revealed normal size as well as two distinct and smooth cystic lesions that were 2 cm in diameter. The examiner diagnosed the Veteran with a painful left spermatocele. The Veteran was provided another VA examination in January 2015. He continued to complain of pain in the left testicle with certain activities such as sitting for more than one hour. He did not receive any treatment for the condition. The examiner noted a left epididymectomy in March 2012. There was no renal or urinary dysfunction due to the left testicular spermatocele. Testicular examination revealed palpable cystic masses without firm mass or nodule. Pain was mild. The examiner noted review of scrotal ultrasounds dated January and December 2012 which revealed no focal solid intratesticular lesions; normal blood flow; stable mildly dilated rete testis; and several cystic lesions in the epididymal head. Considering the totality of evidence in light of the criteria noted above, the Board finds that the preponderance of the evidence weighs against a finding that the Veteran’s left testicular spermatoceles warrant a compensable rating under Diagnostic Code 7525. The evidence does not reflect that this disability is manifested by long-term drug therapy, hospitalizations, or intermittent intensive management, urinary symptoms, or impairment of the Veteran’s renal function. Furthermore, the Veteran has not been diagnosed with a tubular infection, nor an infectious disease, immune disorder or nutritional deficiency; 38 C.F.R. § 4.88b is therefore inapplicable. And, the Veteran is not currently and was not, as of August 19, 1968, service-connected for inactive nonpulmonary tuberculosis; 38 C.F.R. § 4.89 is also inapplicable. The Board has considered whether a compensable rating may be warranted under other potentially applicable Diagnostic Codes, but finds that other Diagnostic Codes are unavailing to the Veteran, based on the evidence of record. See 38 C.F.R. § 4.115b, Diagnostic Codes 7500-7542. For the foregoing reasons, the Board finds that the Veteran is not entitled to a compensable rating for his left testicular spermatoceles during any period under consideration; there is no doubt to be resolved; and the Veteran’s claim must be denied. Tinea pedis The Veteran’s tinea pedis is evaluated as noncompensable under Diagnostic Codes 7813-7806 (dermatophytosis; dermatitis or eczema). Diagnostic Code 7813 instructs to rate the disability as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending on the predominant disability. Based on the Veteran’s diagnosis of tinea pedis documented in the medical evidence of record and symptoms associated therewith, the Board finds that Diagnostic Code 7806 is the most appropriate Diagnostic Code to rate the Veteran’s disability. At the time of the Veteran’s increased rating claim, under Diagnostic Code 7806, a noncompensable disability rating is warranted when less than 5 percent of the entire body or less than 5 percent of the exposed areas is affected, and; no more than topical therapy required during the past 12-month period. A 10 percent disability rating is warranted when at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than six weeks during the past 12-month period. A 30 percent disability rating is warranted when 20 to 40 percent of the entire body is affected; 20 to 40 percent of exposed areas are affected; or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent disability rating is warranted when more than 40 percent of the entire body or more than 40 percent of exposed areas are affected; or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. 38 C.F.R. § 4.118. After a review of the medical evidence of record, the Board has determined that the current noncompensable evaluation during the period on appeal is appropriate. This medical evidence includes March 2011 and January 2015 VA examinations, which document that the Veteran’s tinea pedis affects less than 5 percent of the total body area and less than 5 percent of the exposed areas affected. Moreover, although constant topical medication was used, it was neither a corticosteroid nor an immunosuppressive. Thus, after a review of the medical and lay evidence, the Board finds that the current noncompensable disability rating is appropriate. Simply put, there is no evidence that at least 5 percent of the entire body, or at least 5 percent of the exposed areas are affected, or that the Veteran required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period during the period on appeal. Johnson v. Shulkin, 862 F.3d 1351 (2017). The Board notes that the current noncompensable disability rating was awarded effective July 31, 2009. The Board notes the implementation of revised Diagnostic Criteria for skin disorders by VA in July 2018, effective August 13, 2018. To the extent that such criteria would be applicable here, they would not warrant an increased evaluation either. In short, the competent medical and lay evidence of record reflects that the noncompensable disability rating during the period on appeal is appropriate. Scars, left thigh status post shrapnel wound The Veteran’s scars of the left thigh status post shrapnel wounds are evaluated as noncompensable pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7805, which instructs to rate scars and effect of scars under Diagnostic Codes 7800, 7801, 7802, and 7804. The Board notes that Diagnostic Code 7800, which pertains to scars of the head, face, or neck, is not applicable. Under 38 C.F.R. § 4.118, Diagnostic Code 7801, a 10 percent rating is warranted for a scar not of the head, face, or neck that are deep and nonlinear and has an area or area of at least 6 square inches (30 sq. cm.) but less than 12 square inches (77 sq. cm.). Under 38 C.F.R. § 4.118, Diagnostic Code 7802, a 10 percent rating is warranted for a scar not of the head, face or neck, that is superficial and nonlinear and have an area or areas of 144 square inches (929 sq. cm.) or greater. Under 38 C.F.R. § 4.118, Diagnostic Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. Crucially, the evidence of record indicates that other than reports of partial numbness, the Veteran’s scars are asymptomatic. The relevant evidence pertaining to the Veteran’s scars of the left thigh status post shrapnel wound consist of VA examinations reports dated March 2011 and January 2015 as well as a March 2018 private treatment report from Dr. J.H. Notably, the January 2015 VA examination report documents a scar over the left distal lateral thigh just above knee measuring 2 cm; a scar on the left lateral mid-thigh measuring 4 cm; and a scar of the left lateral distal calf measuring 3 cm. Pertinently, there are no findings that the scars are not painful or unstable, and that the total area of the scars are 39 square cm or greater. Accordingly, the Board finds that a compensable rating is not warranted for the Veteran’s scars of the left thigh status post shrapnel wound. Extraschedular consideration With regard to extraschedular consideration, neither the Veteran nor his attorney has raised any issue pertaining to this matter, nor have any other issues pertaining to extraschedular consideration been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. Ap. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Service connection for cervical spine disability, right leg sciatica, and bilateral foot disability With respect to the Veteran’s claim of service connection for a cervical spine disability, bilateral foot disability, and right leg sciatica, the Veteran contends that he has a cervical spine disability, bilateral foot disability, and right leg sciatica that are related to his service, to include performing his duties as a pilot during combat service in Vietnam. See, e.g., the March 2018 Board hearing transcript, page 13; see also a statement from the Veteran dated December 2009. The Veteran’s service treatment records are absent complaints of or treatment for a cervical spine disability, bilateral foot disability, or right leg sciatica. However, as discussed above, the Board finds the Veteran credible as to his reported in-service injury from performing his duties as a helicopter pilot which include a forced landing in 1969. Moreover, an October 2007 CT scan of the cervical spine reveals an impression of mild multilevel degenerative changes without significant central canal or neural foraminal compromise. Also, an X-ray report from M.G., D.P.M. dated February 2002 documents plantar fasciitis and plantar calcaneal spur. Further, the March 2018 private treatment record from Dr. J.H. indicates that the Veteran has neurological impairment of the right lower extremity. There is no medical opinion of record as to whether the Veteran has a cervical spine disability, bilateral foot disability, or right leg sciatica that is related to service. In light of the foregoing, the Board finds that a medical opinion for such should be obtained on remand. Additionally, a medical opinion should be obtained as to whether the Veteran has right leg sciatica that is secondary to his now service-connected degenerative disc disease of the lumbar spine. Higher evaluations for recurrent major depressive disorder, degenerative joint disease of the left shoulder with residual scars, degenerative joint disease of the right wrist status post right wrist fracture, and residual of right thumb fracture With regard to the Veteran’s claim of entitlement to an increased disability rating for recurrent major depressive disorder, the Veteran’s most recent VA examination for this disability was in January 2015. Pertinently, the Veteran indicated at the March 2018 Board hearing that his disability has become worse since the VA examination. Specifically, the Veteran reported social isolation, impairment of memory, and decreased concentration. See the March 2018 Board hearing transcript, pgs. 9-10, 15-16. Notably, these symptoms were not documented during the January 2015 VA examination. Therefore, the Board finds that a contemporaneous VA examination is warranted to ascertain the current severity of the Veteran’s recurrent major depressive disorder. See Snuffer v. Gober, 10 Vet. App. 400 (1997) [a veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination]. With respect to the Veteran’s claims of increased ratings for degenerative joint disease of the left shoulder with residual scars, degenerative joint disease of the right wrist status post right wrist fracture, and residual of right thumb fracture, the Veteran was most recently provided a VA examination for these disabilities in January 2015. Pertinently, the Veteran indicated at the March 2018 Board hearing that he has increased limitation of left shoulder motion since the January 2015 VA examination. Also, the March 2018 private treatment record from Dr. J.H. indicates that the Veteran has increased limitation of motion of his right thumb. Further, a March 2016 private treatment record from Dr. B.M. documents neurological impairment associated with the Veteran’s degenerative joint disease of the right wrist. As this evidence therefore indicates that the Veteran may be entitled to higher disability ratings for his degenerative joint disease of the left shoulder with scars as well as his residual of right thumb fracture and may also be entitled to a separate rating for neurological impairment associated with his degenerative joint disease of the right wrist status post right wrist fracture, the Board finds that contemporaneous VA examinations are warranted to ascertain the current severity of the Veteran’s disabilities. Service connection for residuals of Piroxicam causing truncal vagotomy (claimed as stomach surgery) Because the medication may have been proved for service connected disability, the issue of secondary service connection has been raised by the record. TDIU The Board notes that the claim of entitlement to TDIU is inextricably intertwined with the service connection and increased rating claims remanded herein. In other words, development of these claims may impact his TDIU claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) [two or more issues are inextricably intertwined if one claim could have significant impact on the other]. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of his cervical spine disability, bilateral foot disability, and right leg sciatica. The claims folder must be made available to the examiner. The examiner should then provide an opinion as to the following: a. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a cervical spine disability that is related to his service, to include his duties as a helicopter pilot which involved a forced landing in 1969. b. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a bilateral foot disability that is related to his service, to include his duties as a helicopter pilot which involved a forced landing in 1969. c. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran has right leg sciatica that is related to his service, to include his duties as a helicopter pilot which involved a forced landing in 1969. d. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran has right leg sciatica that is caused or aggravated by his service-connected degenerative disc disease of the lumbar spine. The examiner must provide a rationale for his or her opinion. 2. The Veteran must be afforded a VA examination for the purpose of determining the current severity of his service-connected recurrent major depressive disorder. The examiner should describe in detail all current symptoms of the Veteran’s recurrent major depressive disorder. All tests and studies deemed necessary by the examiner should be performed. A complete rationale for all opinions must be provided. 3. Schedule the Veteran for appropriate VA examination(s) to assess the orthopedic manifestations of the Veteran’s service-connected degenerative joint disease of the left shoulder with residual scars, degenerative joint disease of the right wrist status post right wrist fracture, and residual of right thumb fracture. The claims folder must be reviewed in conjunction with the examination. All testing deemed necessary must be conducted and results reported in detail. Regarding the orthopedic manifestations, the examiner is asked to indicate the point during range of motion testing that motion is limited by pain. The examiner should describe in detail the presence or absence and the extent of any functional loss due to weakened movement, excess fatigability, incoordination, or pain on use, and should state whether any pain claimed by the Veteran is supported by adequate pathology, e.g., muscle spasm, and is evidenced by his visible behavior, e.g., facial expression or wincing, on pressure or manipulation. The examiner should express an opinion as to whether pain or other manifestations occurring during flare-ups or with repeated use could significantly limit functional ability of the affected part. The examiner should portray the degree of any additional range of motion loss due to pain on use or during flare-ups. The examiner should test the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing for the right wrist, left wrist, right thumb, left thumb, right shoulder, and left shoulder. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. Regarding any neurological impairment, in particular neurological impairment associated with the right wrist, the examiner must render an opinion as to the current severity of the Veteran’s neurological impairment. The examiner should note the symptomatology attributable to the neurological impairment and comment as to whether the symptoms are best described as mild, moderate, or severe incomplete nerve paralysis or complete paralysis. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached should be provided. 4. The AOJ should review the record, determine whether the secondary service connection issue may be adjudicated or whether the appellant must complete the appropriate form. Action, as appropriate should be taken.   5. Review the claims folder to ensure that all of the foregoing requested development is completed, and arrange for any additional development indicated. Then readjudicate the claims on appeal. If any of the benefits sought remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and his attorney with the requisite period of time to respond. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Arif Syed, Counsel