Citation Nr: 18156559 Decision Date: 12/11/18 Archive Date: 12/10/18 DOCKET NO. 16-28 017 DATE: December 11, 2018 ORDER The claim of entitlement to service connection for gout is reopened. Service connection for a lower back condition is denied. Service connection for diabetes mellitus is denied. Service connection for hemorrhoids is denied. Service connection for knot on groin (also claimed as lymph node condition and possible hernia) is denied. Service connection for chronic laryngitis (claimed as sinusitis) is granted. A compensable evaluation for bilateral hearing loss is denied. A 10 percent evaluation for surgical scar on the neck, status post cyst removal is granted. REMANDED Entitlement to service connection for gout, also claimed as toe condition is remanded. Entitlement to service connection for coronary artery disease is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for headaches, to include as secondary to service-connected tinnitus and/or laryngitis is remanded. Entitlement to service connection for a psychiatric disorder is remanded. FINDINGS OF FACT 1. An unappealed January 2004 rating decision denied service connection for gout; no new and material evidence was submitted within one year of the decision. 2. The preponderance of the evidence is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of a low back condition. 3. The preponderance of the evidence is against finding that the Veteran’s diabetes mellitus manifested in service or within a year of service; or is otherwise etiologically related to an in-service injury, event, or disease. 4. The preponderance of the evidence is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of hemorrhoids. 5. The preponderance of the evidence is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of knot on groin (also claimed as lymph node condition and possible hernia). 6. Throughout the appeals period, the Veteran had, at worst, Level II hearing in both ears. 7. The Veteran reports that his scar, status post neck cyst removal is painful; it is superficial and linear without frequent loss of skin covering, or a characteristic of disfigurement. CONCLUSIONS OF LAW 1. New and material evidence has been submitted, and the claim of entitlement to service connection for gout is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 2. The criteria for service connection for a low back condition have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1110, 1111, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). 4. The criteria for service connection for hemorrhoids have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 5. The criteria for service connection for a knot on groin (also claimed as lymph node condition and possible hernia) have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 6. The criteria for service connection for chronic laryngitis (also claimed as sinus condition) have been met. 38 U.S.C. §§ 1110, 1131, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 7. The criteria for a compensable evaluation for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.85, 4.86, Diagnostic Code (DC) 6260. 8. The criteria for a 10 percent rating for surgical scar on neck, status post cyst removal have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.27, 4.118, DC 7800, 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1973 to May 1993. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from October 2014 and May 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The claim of entitlement to service connection for a sinus condition has been recharacterized as one for an ear, nose and throat condition (specifically laryngitis) based on the lay contentions and medical evidence of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) Reopened Claim The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. In an unappealed January 2004 rating decision, the RO denied service connection for gout due to the lack of a current disability. No new and material evidence was submitted within one year of notice of that decision and the Veteran’s appellate rights. Thus, the decision became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. A petition to reopen this claim was filed in April 2013. A July 2013 treatment record shows a diagnosis of gout in the Veteran’s active problem list. Thus, new and material evidence has been received and the claim is reopened. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Certain chronic diseases will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). 1. Service connection for a low back condition The Veteran seeks service connection for a low back condition. See April 2013 correspondence/claim. Service treatment records include a complaint of mid-back pain with spasm, assessed as a back strain. See March 1988 service treatment record. A March 1993 examination for retirement showed no back disorders; the Veteran indicated good health in the related report of medical history. Post-service, the Veteran complained of a back pain related to lifting something at work in July 2005 treatment records. Examination of the back was normal and no diagnosis was given. The Veteran also complained of back pain in April 2011 treatment records. Examination showed tenderness and an assessment of lumbago was given. The Veteran was afforded a VA examination in July 2013. The examiner completed a Disability Benefit Questionnaire (DBQ) and provided a medical opinion. The Veteran reported a lower back condition which had onset in the 1980s secondary to a line of duty injury. Upon testing, the examiner noted results within normal limits, including full range of motion and no objective evidence of pain. The examiner noted associated July 2013 imaging did not document arthritis. The examiner indicated no functional or occupational impact. The examiner indicated that no diagnosis related to the lower back exists; there was no pathology to render a diagnosis. Although the examiner endorsed that the condition was more likely than not related to service, the examiner noted that the present examination was normal. Further, the examiner explained status post applies to the condition in question and indicated that any back condition has resolved. Service connection is not warranted in this case as no disability exists, or existed during the pendency of this appeal. The Board finds the July 2013 DBQ and medical opinion adequate. The examiner has the appropriate training, expertise and knowledge to evaluate the claimed disability. The examiner provided a thorough and cogent rationale for his finding and opinion, which included consideration of the Veteran’s reported symptoms both during and after service, and the post-service clinical history. Although the examiner indicated a positive nexus, the collective opinion shows that the present examination and imaging rules out any current disability. A current disability is generally shown by evidence after the claim is submitted or shortly before. Romanowski v. Shinseki, 26 Vet. App. 289, 294 (2013). Here the evidence does not support a finding that a lower back condition existed during the appeal period. The DBQ examiner noted no current condition exists; treatment records and imaging show no current condition. Although April 2011 treatment records noted a diagnosis of lumbago two years before the claim was submitted, the normal July 2013 examination and lack of complaints in subsequent treatment records support the DBQ examiner’s conclusion that there is no present pathology to render a diagnosis. The Board has considered the Veteran’s lay statements. He is competent to describe observable symptoms including back pain. The Board must determine on a case by case basis whether a particular condition is the type of condition that is within the competence of a layperson to provide an opinion as to etiology. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428 (2011). To the extent the Veteran asserts back pain, the record does not show that he has the skills, training, or experience needed to determine that his symptoms are due to a underlying clinical condition. The medical findings, including the examiner’s interpretation of imaging studies in this case, are more probative. The Board is cognizant of the ruling in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In that case, the Federal Circuit found that where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. However, the Federal Circuit limited its holding, stating, “[w]e do not hold that a veteran could demonstrate service connection simply by asserting subjective pain. To establish the presence of a disability, the veteran will need to show that his pain reaches the level of functional impairment of earning capacity.” In other words, subjective pain in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. In this case, there is no indication or assertion that the Veteran experiences any functional impairment that affects earning capacity. The July 2013 VA examiner found that the Veteran had full range of motion with no objective evidence of painful motion, no functional loss or impairment, and there was no impact on his ability to work. Given the lack of functional impairment or a clinical diagnosis, the evidence does not support a finding of a current low back condition. As the preponderance of the evidence shows that there is no current condition, service connection cannot be granted. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The benefit of the doubt doctrine is not applicable. See 38 U.S.C. §5107; 38 C.F.R. §3.102; Gilbert v. Derwinski, 1 Vet. App.49, 55 (1990). 2. Service connection for diabetes mellitus The Veteran seeks service connection for diabetes mellitus. See December 2013 facsimile. Service treatment records are silent for complaints or symptoms related to diabetes mellitus. A glucose test was done in conjunction with the Veteran’s March 1993 retirement examination; the glucose test was negative. As noted, the Veteran’s retirement examination showed no abnormality; the Veteran indicated good health. The post-service treatment records show the Veteran was first noted to have elevated blood sugar levels without a diagnosis of diabetes mellitus in January 2004 treatment record. The Veteran was diagnosed with pre-diabetes in June 2005 with the clinician noting that the Veteran did not have diabetes at this point, only glucose intolerance. The Veteran was finally assessed with diabetes in March 2011. Service connection is not warranted in this case. The service treatment records are negative for symptoms, treatment or diagnosis of diabetes mellitus. The condition was not noted in service or within a year of discharge, and there was not continuity thereafter. The Veteran has not asserted chronicity in service or continuity of symptoms since. Accordingly, 38 C.F.R. § 3.303 (b) does not provide an avenue of service connection based on chronicity or continuity of symptomatology. Service connection for diabetes mellitus may also not be presumed as a chronic disease under 38 C.F.R. §§ 3.307, 3.309(a). The claims file otherwise contains no competent opinions linking the Veteran’s disability to service. In sum, the evidence weighs against a nexus between the Veteran’s current diabetes mellitus disability and active military service. Accordingly, the benefit of the doubt doctrine does not apply. Service connection is not warranted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 3. Service connection for hemorrhoids, also claimed as anal fissures and pruritus The Veteran seeks service connection for hemorrhoid, also claimed as pruritus and anal fissures. The Veteran was treated numerous time in service for anal pruritus, hemorrhoids, and anal fissures. See e.g. April 1978, November 1987, and May 1991 service treatment records. Post-service, the Veteran was treated for external and internal hemorrhoids. See October 2005 treatment records. Internal hemorrhoids were noted on the Veteran’s active problem list in February 2007 and May 2011 treatment records. Thereafter, treatment records are silent for complaints or diagnosis related to hemorrhoids. At the July 2013 VA examination, the Veteran reported hemorrhoids, fissures and pruritus that began in service without a formal diagnosis ever being given. There were no current symptoms or treatment reported. The Veteran declined a clinical examination. Ultimately, the examiner noted no current diagnosis of hemorrhoids, pruritus or fissures as there was no current pathology to render a diagnosis. The examiner noted the in-service treatment, but explained that the condition had resolved and was classified as ‘status post.’ Service connection is not warranted in this case as no disability exists, or existed during the pendency of this appeal. Initially, the Board notes that the duty to assist is not a one-way-street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). It is the responsibility of claimants to cooperate with VA. See Olson v. Principi, 3 Vet. App. 480, 483 (1992). This responsibility extends to examinations. The Veteran has declined a physical examination of his anal region. There is also no assertion that the July 2013 DBQ is inadequate. Finally, the July 2013 DBQ and opinion is based on review of the records and further action is not necessary in connection with the claim. There are no other treatment records or any other examinations showing a current hemorrhoid condition. The Board has considered the Veteran’s lay statements. He is competent to describe observable symptoms. The Veteran has not asserted current symptoms; in fact, he denied any during the July 2013 exam. As the preponderance of the evidence shows that there is no current disability related to hemorrhoids, service connection cannot be granted. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the preponderance of the evidence is against this claim, the benefit of the doubt doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App.49, 55 (1990). 4. Service connection for knot on groin, also claimed as lymph node condition and possible hernia The Veteran seeks service connection for knot on the groin, also claimed as lymph node condition and hernia. See April 2013 correspondence/claim. Service treatment records include complaints of enlarged lymph nodes on the left and right groin with pain upon palpation. See May 1976 service treatment record. An assessment of questionable hernia was given. The March 1993 examination for retirement showed no related disorders; the Veteran did not endorse any hernia and indicated good health. Post-service treatment records are silent for complaint, treatment, or diagnosis related to this condition. In treatment records from 2007 and 2008, the clinicians noted no hernia were discovered upon examination. See March 2007, June 2007, and December 2008 treatment records. Likewise, the Veteran was noted to have no hernia in March 2013 treatment record. The Veteran underwent a VA examination in July 2013 relating to the male reproductive system. The examiner noted no diagnosis of any condition of the male reproductive system including knot in the groin. The examiner noted the Veteran’s report that the condition onset in 1980 while in active duty. However, no physical examination was undertaken upon request of the Veteran. The examiner noted review of the claims file and records. Ultimately, the examiner noted no pathology to render a diagnosis. Service connection is not warranted in this case as no disability exists, or existed during the pendency of this appeal. As noted, the Board notes that the duty to assist is not a one-way-street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). It is the responsibility of claimants to cooperate with VA. See Olson v. Principi, 3 Vet. App. 480, 483 (1992). As the Veteran has been noted to decline the examination, he has not requested a new examination, and the examiner has offered an adequate opinion based on review of the records, further action is not necessary in connection with the claim. The Board finds the July 2013 medical examination and report adequate. The examiner has the appropriate training, expertise and knowledge to evaluate the claimed disability. The examiner provided a thorough and cogent rationale for his finding and opinion, which included consideration of the Veteran’s reported symptoms both during and after service, and the post-service clinical history. The opinion shows that the present pathology does not support a current disability. This is probative evidence against a finding that the Veteran has a current diagnosis. Here the evidence does not show a groin, lymph node, or hernia condition during the appeal period. The VA examiner noted no current condition exists; treatment records and examinations do not support a current condition. The Board has considered the Veteran’s lay statements. While the evidence is void of any complaint related to knot on the groin, lymph nodes or hernia, the Veteran’s assertions would have less probative than the medical evidence including the examinations in treatment records. The record does not show that he has the skills, training, or experience needed to determine that the symptoms he experiences are due to a diagnosable lymph node or hernia condition. The medical findings, including the examiner’s opinion, are more probative. The Veteran has not asserted any pain or associated function limitation implicating Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In this case, there is no indication that the Veteran experiences functional impairment. As the preponderance of the evidence shows that there is no current disability, service connection cannot be granted. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The benefit of the doubt doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App.49, 55 (1990). 5. Service connection for laryngitis is granted. In the Veteran’s April 2013 informal claim, he indicated that he desired service connection for a sinus condition. On his notice of disagreement, he asserted that he was seeking service connection also for a larynx condition that was noted by the VA examiner. After reviewing the evidence, the Board finds that the Veteran is essentially seeking service connection for an ear, nose and throat condition- described as either a sinus or larynx condition. See Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009); Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran’s military personnel records show that he served a period of 20 years, many of which were as a drill instructor and drill sergeant. Looking at the claim through that lens, the Board notes that chronic sinusitis is not noted in the service treatment records. At a VA (sinusitis, rhinitis and other conditions of the nose, throat, larynx) examination in August 2013, the examiner determined that the Veteran did not have a current diagnosis of sinusitis. However, during the examination, the examiner did endorse a current diagnosis of chronic laryngitis noting that a laryngoscopy shows mild chronic rhinitis and severe chronic laryngitis. The examiner indicated that the Veteran had undergone a partial laryngectomy, the residuals of which are related to his voice strain due to years of training troops. Considering the record, the Board finds service connection for chronic laryngitis is warranted. The Veteran’s military duties were as a drill sergeant and instructor, which required him to yell and strain his voice, according to his credible report to the VA examiner. The Board finds such report is consistent with the nature and circumstances of his service. 38 U.S.C. § 1154 (a). That same VA examiner has indicated that his current partial laryngectomy residuals, presumably due to his diagnosed mild chronic laryngitis, are related to his military duties. There is no competent evidence to the contrary. Hence, service connection is warranted. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities found in 38 C.F.R. Part 4. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The assignment of staged ratings is also appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 6. A compensable evaluation for bilateral hearing loss The Veteran seeks a compensable evaluation for bilateral hearing loss, to include separate evaluations for each ear. See November 2013 correspondence. The Veteran reports that his hearing loss interferes with everyday activities. See May 2015 notice of disagreement. Hearing loss ratings range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with average hearing thresholds determined by puretone audiometric testing at frequencies of 1000, 2000, 3000 and 4000 cycles per second. “Puretone threshold average” is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz divided by four. This average is used in all cases (including those in § 4.86) to determine the Roman numeral designation for hearing impairment from Table VI or VIA. 38 C.F.R. § 4.85, Diagnostic Code 6100. The rating schedule at 38 C.F.R. § 4.85 establishes eleven auditory acuity levels, designated from Level I, for essentially normal hearing acuity, through Level XI, for profound deafness. The horizontal rows in Table VI represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. The vertical columns in Table VI represent nine categories of decibel loss based on the pure tone audiometry test. The Roman numeral designation is located at the point where the percentage of speech discrimination and pure tone threshold average intersect. Under certain exceptional patterns of hearing impairment, auditory acuity levels may be calculated using either Table VI, as described above, or Table VIA, which derives a Roman numeral designation based solely on the pure tone audiometry test. 38 C.F.R. § 4.86 (2017). However, as the Veteran has not demonstrated these exceptional patterns of hearing impairment, these criteria are not applicable in this case. In August 2013, the Veteran underwent examination in relation to his claim for service connection. On the authorized audiological evaluation, puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Avg RIGHT 20 15 50 65 37.5 LEFT 15 15 30 30 22.5 Speech audiometry revealed speech recognition ability of 88 percent bilaterally. These results corresponded to Level II hearing in the right and left ears, pursuant to Table VI. Pursuant to Table VII, these Levels result in a 0 percent evaluation. Based on the results of the audiological evaluations discussed above, the Veteran’s bilateral hearing loss has not approximated the criteria for a compensable rating at any time during the appeal period. The Board does not discount the difficulties the Veteran has with his auditory acuity. However, the Board has no discretion in this matter and must predicate its determination on the basis of the results of the audiology studies of record. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992) Moreover, the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment as these are the effects that VA’s audiometric tests are designed to measure. Doucette v. Shulkin, 28 Vet. App. 377 (2017). The Veteran’s hearing loss has not produced functional effects not contemplated by the rating schedule. Additionally, hearing loss is a single disability and 38 C.F.R. §§ 4.85-4.87 provide for a single rating for bilateral hearing loss under Diagnostic Code 6100 as discussed above. Accordingly, separate ratings for right and left ear hearing loss are not permissible. Accordingly, an initial compensable rating or separate ratings for bilateral hearing loss is not warranted at any point on appeal. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. There are no additional expressly or reasonably raised issues presented on the record. 7. A 10 percent for surgical scar on neck, status post cyst removal is granted. The Veteran’s surgical scar on the neck, status post cyst removal scar is rated as noncompensable pursuant to 38 C.F.R. § 4.118, Diagnostic Code (DC) 7800. The criteria pertaining to ratings for the skin were revised effective August 13, 2018. Neither DC 7800 or 7804 were affected by those revisions. Further, the evidence in question all predates August 13, 2018. Thus, the Board will apply the criteria in effect prior to August 13, 2018. The Veteran’s scar of neck, status post cyst removal surgery is evaluated as non-compensable under DC 7800 for burn scars, scars due to other causes, or other disfigurement of the head, face, or neck. 38 C.F.R. § 4.118 DC 7800. Under DC 7800, a 10 percent rating is warranted for scars that are located on the head, face, or neck when there is one characteristic of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. A 30 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, or lips), or; with two or three characteristics of disfigurement. A 50 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. A maximum 80 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. For purposes of evaluation of under 38 C.F.R. § 4.118, the eight characteristics of disfigurement are: a scar that is five or more inches, or thirteen centimeters, in length; a scar that is at least one-quarter of an inch, or 0.6 centimeters, wide at the widest part; surface contour of the scar that is elevated or depressed on palpation; a scar that is adherent to underlying tissue; skin that is hypo- or hyper-pigmented in an area exceeding six square inches, or 39 square centimeters; skin texture that is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches, or 39 square centimeters; underlying soft tissue that is missing in an area exceeding six square inches, or 39 square centimeters; and skin that is indurated and inflexible in an area exceeding six square inches, or 39 square centimeters. 38 C.F.R. § 4.118, DC 7800, Note 1. VA is to consider unretouched color photographs when evaluating under these criteria. Id. at Note 3. Additionally, VA is to separately evaluate disabling effects other than disfigurement that are associated with individual scars of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply 38 C.F.R. § 4.25 (2016) to combine the evaluation(s) with the evaluation assigned under DC 7800. Id. at Note 4. Finally, the characteristics of disfigurement may be caused by one scar or by multiple scars; the characteristics that are required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. Id. at Note 5. Under DC 7804, one or two scars that are unstable or painful warrant a 10 percent rating. A 20 percent rating under DC 7804 requires three or four scars that are unstable or painful, and a 30 percent rating under DC 7804 five or more scars that are unstable or painful. Note (1) following DC 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) following DC 7804 provides that if one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is based on the total number of unstable or painful scars. Note (3) following DC 7804 provides that scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an additional rating under DC 7804 when applicable. 38 C.F.R. § 4.118, DC 7804 (2017). The pertinent evidence consists of the Veteran’s lay descriptions of his scar and a July 2013 VA examination report. The current treatment records are silent for treatment or complaints related to the scar from his neck cyst removal. The Veteran asserts that the scar is tight, painful, and unstable. See November 2013 correspondence; May 2015 notice of disagreement. The July 2013 examiner noted a scar in the area of the neck. The examiner indicated that the scar is not painful and does not involve frequent loss of covering of skin. The scar measured 1 centimeter by 0.1 centimeter. No elevation, depression, adherence to underlying tissue, or missing soft underlying tissue was noted. Further, the examiner noted no abnormality as to pigmentation or texture. There was no distortion or asymmetry of facial features or visible, or palpable tissue loss. The examiner indicated that the scar did not result in functional or occupation limitation. There were no other relevant physical findings. Based on the foregoing, the Veteran’s scar, status post neck cyst removal warrants no more than a 10 percent under DC 7804. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). The Veteran is competent to report pain which he can feel. DC 7804 does not require objective confirmation of such pain or tenderness upon palpation. With regard to whether there is competent and probative evidence of the scar being unstable, the Board finds the July 2013 VA examiner’s opinion (that the scar was not unstable upon examination) more probative. The Veteran’s treatment records are also silent as to loss of covering of the skin or similar symptoms. A 20 percent rating is not warranted under DC 7804 as there is only a single scar. As for a compensable rating under DC 7800, the Board finds one is not warranted based on the objective findings. The July 2013 VA examination findings show there are no characteristics of disfigurements. As such, the Board finds the competent and credible evidence does not support a compensable rating under DC 7800. Further, the Board has also considered evaluations pursuant to 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802 and 7805; however, these diagnostic codes would not provide higher or separate ratings (using the former or revised criteria). These Codes only provide for a 10 percent rating, which the Veteran already is assigned. Further, the scar is not deep, nonlinear or associated with underlying soft tissue damage such that these Codes are even applicable. No functional impairment has been observed or reported such that DC 7805 is applicable. Resolving all reasonable doubt in the Veteran’s favor, a 10 percent rating, but no higher, is assigned for the Veteran’s scar, status post neck cyst removal under DC 7804. There are no additional expressly or reasonably raised issues presented on the record. REASONS FOR REMAND 1. Service connection for gout, also claimed as toe condition is remanded. The Veteran seeks service connection for gout. The Veteran complained of big toe pain with edema in service; the January 1992 assessment was possible gout. In a July 2013 DBQ, the examiner found no current diagnosis of the foot. However, January 2013 treatment records noted gout in the Veteran’s personal medical history and assessments. July 2013 treatment record also noted gout in the Veteran’s active problem list. Finally, July 2013 imaging showed cortical thickening of the second through fourth proximal phalangeal which may represent sequela of chronic inflammation. Accordingly, the Board finds that a remand for an examination and opinion to clarify the Veteran’s current diagnosis is necessary. 2. Service connection for coronary artery disease is remanded. The Veteran seeks service connection for coronary artery disease, to include as secondary to hypertension. See December 2013 facsimile. The Veteran’s service treatment records include a March 1993 electrocardiogram (EKG). The results showed sinus bradycardia and early repolarization. In January 2004, the Veteran was noted to have an acute myocardial infarction. In June 2007, the Veteran was assessed with asymptomatic coronary arteriosclerosis because the EKG showed early repolarization with premature ventricular contraction. The evidence of record does not include an examination and opinion on the matter. Thus, the Board finds a remand is necessary. 3. Service connection for hypertension is remanded. The Veteran seeks service-connection for his diagnosed hypertension as secondary to service-connected disabilities. See November 2014 correspondence. The evidence of record does not include an examination and opinion on the matter. Accordingly, an examination and opinion is necessary. 4. Service connection for erectile dysfunction is remanded. The Veteran seeks service connection for erectile dysfunction. A December 2004 treatment record notes the Veteran’s erectile dysfunction is due to his other physical conditions. At the time, the Veteran’s other physical conditions included a heart condition. As the Board is remanding the claim for a heart condition, the Board will also remand this intertwined issue and defer adjudication at this time. 5. Service connection for headaches is remanded. The Veteran seeks service connection for his headache condition. The July 2013 DBQ for headaches noted a diagnosis of tension migraines. In a July 2016 VA Form 9, the Veteran asserted that his headache condition is secondary to service-connected tinnitus. He also asserts that it may be related to his claimed rhinitis condition, now service-connected as chronic laryngitis. There is no opinion of record as to whether the Veteran’s headache condition is proximately due to or aggravated by his service-connected tinnitus or chronic laryngitis. As such, a remand is necessary.   6. Service connection for an acquired psychiatric disorder is remanded. The Veteran seeks service connection for a psychiatric disorder, to include PTSD. See Clemons. The Veteran relates his condition(s) to his experience in service, to include patrol of the demilitarized zone (DMZ) in Korea and deployments to Germany and Panama. See April 2013 VA 21-0781; March 2013 treatment records; and December 2013 facsimile. In particular, he asserts that he was in fear of his life while stationed on the DMZ. To date, no specific development has been conducted with respect to the Veteran’s stressor. Additional development should be undertaken on remand to determine the nature of the Veteran’s claimed “hostile” DMZ/Korea service. The Veteran has diagnoses that include mood disorder, nightmare disorder, and depressive disorder. However, he has not been afforded an examination. One should be provided. The matters are REMANDED for the following action: 1. Make an additional attempt to verify any of the Veteran’s claimed in-service stressors, including his service in Korea along the DMZ. Notify the Veteran that he may submit any further clarifying medical or lay evidence including, but not limited to, official records in his possession, in-service letters that he received or sent, photographs, statements from service colleagues (“buddy statements”), or any other evidence referable to the claimed in-service incidents. Advise him that, if possible, he should provide names of other individuals who were also present and witnessed or knew of his claimed stressor incidents, or who can confirm his proximity to them. If appropriate, issue a formal finding regarding the lack of information required to corroborate the claimed stressors. The Veteran and his representative are also to be notified of such finding. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his gout. The claims file must be made available to the VA examiner for review. If the examiner finds no current diagnosis, the examiner must reconcile that finding with the treatment records noting gout in the active problem list. The examiner must opine whether gout is at least as likely as not related to an in-service injury, event, or disease, including an in-service report of toe pain. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed heart conditions, to include coronary artery disease and hypertension. The claims file must be made available to the VA examiner for review. a) The examiner must opine whether it is at least as likely as not that a current heart condition had onset during service; or, is otherwise related to an in-service injury, event, or disease, including the March 1994 ECG which showed early repolarization. b) The examiner must also opine whether it is at least as likely as not that any current ischemic heart disease (to include coronary artery disease) or hypertension manifested within one year after discharge from service. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed erectile dysfunction. The claims file must be made available to the VA examiner for review. a) The examiner must opine whether it is at least as likely as not that erectile dysfunction had onset during service; or, is otherwise related to service. b) The examiner should opine as to whether the Veteran’s erectile dysfunction is at least as likely as not proximately due to a service-connected disability or aggravated beyond its natural progression by a service-connected disability. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his headache condition. The claims file must be made available to the VA examiner for review. a) The examiner is asked to identify all current headache disorders. If the examiner finds no current diagnosis, the examiner must reconcile that finding with the July 2013 diagnosis of tension migraine. b) If there is a diagnosis, the examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the in-service reports of headaches. c) The examiner should also opine as to whether the Veteran’s headache condition is at least as likely as not proximately due to his service-connected tinnitus or chronic laryngitis disabilities OR, aggravated beyond its natural progression by either service-connected disability. 6. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder. The claims file must be made available to the VA examiner for review. a) The examiner is asked to identify all current psychiatric disorders. For any psychiatric disorder that is noted in the treatment records, but not found on current examination, the examiner should attempt to reconcile these findings. b) The examiner must opine whether the Veteran has a current diagnosis of PTSD. If the examiner determines that PTSD is present, then he or she must specify the stressor supporting that diagnosis, to include whether such diagnosis is the result of his fear of hostile military or terrorist activity coincident with his service in Korea along the DMZ (if confirmed by the service records/JSRRC). c) With respect to any additional psychiatric disorder present during the period of this claim, state whether it is at least as likely as not that such disorder originated during service or is otherwise etiologically related to service. (Continued on the next page)   7. The RO should ensure that rationales are provided for each of the requested opinions noted above. If any examiner(s) feels that any requested opinion cannot be rendered without resorting to speculation, then such examiner(s) must explain why this is so. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Vuong, Associate Counsel