Citation Nr: 18156969 Decision Date: 12/11/18 Archive Date: 12/11/18 DOCKET NO. 16-36 809 DATE: December 11, 2018 ORDER Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus type 2, is denied. Entitlement to service connection for steatosis, to include as secondary to diabetes mellitus type 2, is denied. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus type 2, is granted. Entitlement to service connection for left ear hearing loss is granted. Entitlement to an initial rating of 20 percent, but no greater, for diabetic polyneuropathy of the left lower extremity is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial rating of 20 percent, but no greater, for diabetic polyneuropathy of the right lower extremity is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for right ear hearing loss is remanded. FINDINGS OF FACT 1. The Veteran’s hypertension is neither proximately due to nor aggravated beyond it natural progression by service-connected diabetes mellitus type 2, and is not otherwise related to an in-service injury, event, or disease. 2. The Veteran’s steatosis is neither proximately due to nor aggravated beyond it natural progression by service-connected diabetes mellitus type 2, and is not otherwise related to an in-service injury, event, or disease. 3. Resolving reasonable doubt in the Veteran’s favor, erectile dysfunction is proximately due to service-connected diabetes mellitus type 2. 4. Resolving reasonable doubt in the Veteran’s favor, left ear hearing loss is at least as likely as not related to in-service acoustic trauma. 5. The Veteran’s diabetic polyneuropathy of the left lower extremity is characterized by moderate, incomplete paralysis. 6. The Veteran’s diabetic polyneuropathy of the right lower extremity is characterized by moderate, incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension, on a direct basis or secondary to diabetes mellitus type 2, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for service connection for steatosis, on a direct basis or secondary to diabetes mellitus type 2, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for service connection for erectile dysfunction as secondary to diabetes mellitus type 2 have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 4. The criteria for service connection for left ear hearing loss have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.385. 5. The criteria for an initial disability rating of 20 percent, but no greater, for diabetic polyneuropathy of the left lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1–4.14, 4.124a, Diagnostic Code 8521. 6. The criteria for an initial disability rating of 20 percent, but no greater, for diabetic polyneuropathy of the right lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1–4.14, 4.124a, Diagnostic Code 8521. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from January 1968 to October 1972. By correspondence received November 2018, the Veteran withdrew is prior request for a hearing. The Board finds that the June 2014 statement in support of claim is a notice of disagreement (NOD) that was timely filed in response to the December 2013 rating decision denying entitlement to service connection for bilateral hearing loss and the February 2014 rating decision denying entitlement to service connection for erectile dysfunction, hypertension, and steatosis. In June 2014, the Veteran filed a statement in support of claim stating: “This is a Request for Reconsideration of all conditions contained in the rating decision dated 11 Feb 2014.” That decision denied entitlement to service connection for erectile dysfunction, hypertension, and steatosis. The Veteran further indicated his disagreement with the denial of entitlement to service connection for bilateral hearing loss, although that decision was made in the December 2013 rating decision, not the February 2014 rating decision. In a February 2015 rating decision, the RO held that new and material evidence had not been submitted to reopen claims of entitlement to service connection for erectile dysfunction, hypertension, steatosis, and bilateral hearing loss. In other words, the RO interpreted the June 2014 statement as a new claim, not a timely filed NOD to the prior two rating decisions. Prior to September 25, 2014, an NOD did not need to be filed on an official form. See 38 C.F.R. § 20.201 (2014). Rather, at the time of the June 2014 statement, an NOD need only be a “written communication . . . expressing dissatisfaction or disagreement with an adjudicative determination by the [RO] and a desire to contest the result . . . .” Id. Special wording was not required, so long as the NOD was expressed “in terms which can be reasonably construed as disagreement with that determination and a desire for appellate review.” Id. The Veteran’s June 2014 statement satisfied the criteria for an NOD that were in effect prior to September 25, 2014. The Veteran is therefore not required to submit new and material evidence to support the reopening of the claims of entitlement to service connection for erectile dysfunction, hypertension, steatosis, and bilateral hearing loss. 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 military service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). An increase in severity of a nonservice-connected disease or injury shall not be service-connected if it is due to the natural progression of the nonservice-connected condition. Id. at 447–48. Service connection on a secondary basis may not be granted without medical evidence of a current disability and evidence of a nexus between the current disability and a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512–14 (1998). 1. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus type 2 Regarding direct service connection, the first element is satisfied, in that VA and private medical records indicate a current diagnosis of hypertension. The second element is also satisfied, in that the Veteran argues that his hypertension is the result of Agent Orange exposure. See March 2015 private medical opinion. The nexus element is not satisfied. The November 2013 VA medical opinion indicates that the Veteran has essential hypertension and that the etiologies for this disorder “include advancing age, dietary factors and obesity.” The examiner states that the Veteran displays all of these etiologies. Because the Veteran displays these etiologies, the implication is that the Veteran’s hypertension is less likely than not related to service. Since the Veteran has all of the etiologies of essential hypertension and has provided no evidence of a link between herbicide agent exposure and hypertension, the preponderance of the evidence is against the existence of a nexus between a current diagnosis of hypertension and service. Regarding secondary service connection, the nexus element is also not satisfied. The examiner indicates that the Veteran has “essential hypertension and not renal hypertension from diabetes.” This conclusion “is based on the normal renal function on the labwork.” The examiner also states that etiology of essential hypertension is not diabetes, but rather “advancing age, dietary factors and obesity,” all of which the Veteran has. For these reasons, the examiner concludes that the Veteran’s hypertension is less likely than not related to service. These medical opinions are probative because they are based on a review of the record and contain clear conclusions with supporting data connected by a reasoned medical explanation. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301–02 (2008). Because the preponderance of the evidence is against the existence of a nexus between hypertension and service or service-connected diabetes, the Veteran’s claim must be denied. In reaching these conclusions, the Board has considered the April 2014 diabetes DBQ filled out by a private physician. In this DBQ, the examiner checks one box to indicate that the Veteran’s hypertension is at least as likely as not related to diabetes and checks a second box to indicate that the Veteran’s diabetes at least as likely as not aggravated the Veteran’s hypertension. Unfortunately, the DBQ contains no accompanying rationale to support the conclusions indicated by the checked boxes. It is therefore entitled to minimal probative value. By contrast, the November 2013 VA medical opinion is entitled to greater probative value because the conclusions of the VA opinion are supported by a scientific rationale. It follows that the preponderance of the evidence remains against the existence of nexus between hypertension and service or service-connected diabetes. The Board has also considered the March 2015 private medical opinion. This opinion reads in part as follows: “I support [the Veteran’s] disability due to Agent Orange exposure resulting in diabetes mellitus with complications of . . . hypertension . . . .” The private examiner attaches an article in support of this contention, entitled “Treatment of hypertension in patients with diabetes mellitus.” Like the April 2014 DBQ, the conclusion of the March 2015 private medical opinion is not supported by any scientific rationale. By itself, the March 2015 private medical opinion is entitled to minimal probative value. Furthermore, the accompanying article does not by itself or in the context of the evidence as a whole support the existence of a nexus between hypertension and diabetes mellitus type 2. The article notes that hypertension “is a common problem in patients with . . . type 2 diabetes,” quotes a statistic that hypertension was present in 39 percent of a group of 3,500 patients diagnosed with diabetes, and goes on to discuss the medical treatment of individuals with hypertension. Unfortunately, never states that hypertension is caused by diabetes mellitus type 2 or exposure to herbicide agents. Also, the 39 percent statistic is less than 50 percent, which by itself suggests that hypertension is less likely than not related to diabetes mellitus type 2. At best, the hypertension article supports the existence of a correlation between hypertension and diabetes, which by itself is insufficient to establish the existence of a nexus between these disorders. For these reasons, the hypertension article, by itself or in the context of the evidence as a whole, does not support entitlement to service connection for hypertension. Unfortunately, because the preponderance of the evidence remains against the existence of nexus between hypertension and service or service-connected diabetes, entitlement to service connection for hypertension must be denied. 2. Entitlement to service connection for steatosis, to include as secondary to diabetes mellitus type 2 Regarding direct service connection, the first element is satisfied, in that VA and private medical records indicate a current diagnosis of steatosis. The second element is also satisfied, in that the Veteran suggests that his steatosis is the result of Agent Orange exposure. See March 2015 private medical opinion. The nexus element is not satisfied. The November 2013 VA examiner indicates that the etiologies of steatosis are obesity and “ongoing alcohol use.” According to the examiner, the Veteran has both of these etiologies. Since the Veteran has both etiologies for steatosis and has provided no evidence of a nexus between herbicide agent exposure and steatosis, the preponderance of the evidence is against the existence of a nexus between a current diagnosis of steatosis and service. Regarding secondary service connection, the nexus element is also not satisfied. The November 2013 VA examiner states that the Veteran’s steatosis preceded his diabetes. There is no private medical evidence to the contrary. Because steatosis originated prior to diabetes and the Veteran displays the steatosis etiologies of obesity and alcohol use, the examiner concludes that the Veteran’s steatosis is less likely than not related to service-connected diabetes. These medical opinions are probative because they are based on a review of the record and contain clear conclusions with supporting data connected by a reasoned medical explanation. Nieves-Rodriguez, 22 Vet. App. at 301–02. Because the preponderance of the evidence is against the existence of a nexus between steatosis and service or service-connected diabetes, the Veteran’s claim must be denied. In reaching these conclusions, the Board has considered the April 2014 diabetes DBQ filled out by a private physician. As with the hypertension disorder previously discussed, in this DBQ, the examiner checks one box to indicate that the Veteran’s steatosis is at least as likely as not related to diabetes and checks a second box to indicate that the Veteran’s diabetes at least as likely as not aggravated the Veteran’s steatosis. Unfortunately, the DBQ contains no accompanying rationale to support the conclusions indicated by the checked boxes. It is therefore entitled to minimal probative value. By contrast, the November 2013 VA medical opinion is entitled to greater probative value because the conclusions of the VA opinion are supported by a scientific rationale. It follows that the preponderance of the evidence remains against the existence of nexus between steatosis and service or service-connected diabetes. The Board has also considered the March 2015 private medical opinion. This opinion reads in part as follows: “I support [the Veteran’s] disability due to Agent Orange exposure resulting in diabetes mellitus with complications of” steatosis. The private examiner attaches an article in support of this contention, entitled “Epidemiology, clinical features, and diagnosis of nonalcoholic fatty liver disease in adults.” Like the April 2014 DBQ, the conclusion of the March 2015 private medical opinion is not supported by any scientific rationale. By itself, the March 2015 private medical opinion is entitled to minimal probative value. Furthermore, the accompanying article does not by itself or in the context of the evidence as a whole support entitlement to service connection for steatosis. The subject of the article is “nonalcoholic fatty liver disease,” which the article defines as “the presence of hepatic steatosis when no other causes for secondary hepatic fat accumulation (eg, heavy alcohol consumption) are present.” Furthermore, a diagnosis of nonalcoholic fatty liver disease requires “[e]xclusion of significant alcohol consumption.” But the November 2013 VA medical opinion indicates that “ongoing alcohol use” is one of the etiologies of the Veteran’s steatosis. There is no lay or medical evidence to the contrary. Since the steatosis article is directed towards a non-alcoholic type of steatosis that the Veteran does not have, the findings of the article are inapplicable to the Veteran’s alcohol-related steatosis. Even so, the article does not support that the existence of a nexus between Veteran’s diabetes and steatosis. The article notes that diabetes mellitus type 2 is a risk factor for nonalcoholic fatty liver disease and states that patients with this disorder often have “[i]nsulin resistance or overt diabetes.” Unfortunately, correlation does not prove causation, particularly where, as here, the article could just as easily be interpreted to mean that steatosis causes diabetes. At best, the steatosis article supports the existence of a correlation between diabetes and a non-alcoholic type of steatosis that the Veteran does not have. By itself, this evidence of correlation is insufficient to establish the existence of a nexus between diabetes and the alcohol-related type of steatosis that the Veteran does have. Also according to the article, “[t]he most widely supported theory implicates insulin resistance as the key mechanism leading to hepatic steatosis . . . .” This statement would be more probative if was accompanied by a citation or indicated the extent to which the insulin theory is accepted by the scientific community. Unfortunately, as also noted by the article, “[t]he pathogenesis of nonalcoholic fatty liver disease has not been fully elucidated.” Even taking the insulin theory as true, it seems inapplicable where, as here, the November 2013 VA medical opinion states that the Veteran’s steatosis preceded his diabetes. There is no lay or medical evidence to the contrary. Taken together, the steatosis article appears to be directed to a non-alcoholic type of steatosis that the Veteran does not have. The article merely shows correlation without causation while noting that the disease pathology “has not been fully elucidated.” Furthermore, there is uncontroverted medical evidence that the Veteran’s steatosis preceded his diabetes. For these reasons, the steatosis article, by itself or in the context of the evidence as a whole, does not support the existence of a nexus between diabetes and the Veteran’s alcohol-related steatosis. Unfortunately, as with hypertension, because the preponderance of the evidence remains against the existence of nexus between steatosis and service or service-connected diabetes, entitlement to service connection for steatosis must be denied. 3. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus type 2 The evidence is at least in equipoise with regard to the existence of a nexus between erectile dysfunction and service-connected diabetes. For this reason, the Veteran is entitled to prevail with respect to his claim. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55–56 (1990). The November 2013 VA medical opinion concludes that the Veteran’s current diagnosis of erectile dysfunction is less likely than not related to service-connected diabetes mellitus type 2. The examiner’s conclusion is based on the fact that there is no vascular disease, that there is no neuropathy, and the fact that erectile dysfunction is more likely the result of the hypertension medications that he is on. As the examiner does not explain how the absence of vascular disease or neuropathy supports his conclusion, the most probative part of his opinion is his assertion that hypertension medication is the most likely cause of erectile dysfunction. Though no rationale is provided, this conclusion is presumably based on the examiner’s knowledge and experience. Also according to the examiner, the Veteran was diagnosed with erectile dysfunction in 2005. The Board notes that the Veteran was diagnosed with diabetic neuropathy in April 2014. See May 2014 neuropathy DBQ (received 6/30/14). The VA examiner was therefore not in error to assume that there was no neuropathy at the time of the November 2013 examination or at the time of the Veteran’s 2005 diagnosis for erectile dysfunction. In an April 2014 diabetes DBQ filled out by a private physician, the examiner checks one box to indicate that the Veteran’s erectile dysfunction is at least as likely as not related to diabetes and checks a second box to indicate that the Veteran’s diabetes at least as likely as not aggravated the Veteran’s erectile dysfunction. In addition to the diabetes DBQ, the same private physician has also filled out an accompanying June 2014 erectile dysfunction DBQ. That second DBQ states that the Veteran’s erectile dysfunction is the result of “diabetes and medication,” presumably the medication used to treat diabetes. This is a stronger rationale than merely checking boxes, as was done with respect to hypertension and steatosis. In making this statement, the private examiner provides essentially the same rationale submitted by the November 2013 VA examiner, albeit with a different conclusion based on consideration of a different medication. Like the VA examiner, the private examiner provides no underlying basis for this conclusion, but it is presumably based on the private examiner’s knowledge and experience. For erectile dysfunction, the rationales supporting the conclusions contained in the VA opinion and the erectile dysfunction DBQ are not strong. Nevertheless, as the rationales are essentially identical, the opposite conclusions that they support are entitled to equal probative value. As the evidence is at least in equipoise, the Veteran is entitled to prevail with respect to his claim of entitlement to service connection for erectile dysfunction as secondary to diabetes mellitus. 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55–56. The Board notes that the article accompanying the March 2015 private medical opinion does not support entitlement to service connection for erectile dysfunction as secondary to diabetes mellitus type 2. The opinion itself reads in part as follows: “I support [the Veteran’s] disability due to Agent Orange exposure resulting in diabetes mellitus with complications of . . . erectile dysfunction . . . .” The private examiner attaches an article in support of this contention, entitled “Erectile dysfunction in diabetes mellitus.” For reasons already discussed above, the March 2015 private medical opinion does not by itself support a nexus between erectile dysfunction and diabetes because it contains no rationale. The accompanying article also does not support the existence of a nexus. At best, it notes a correlation between erectile dysfunction for men between the ages of 55 and 59. But the Veteran was born in 1943 and was diagnosed with erectile dysfunction in 2005 at the earliest when he was 62 years old. He is therefore outside of the age range indicated in the article. Furthermore, the article goes on to state: “If [erectile dysfunction is] present, the clinician should not automatically assume it is caused by diabetes, but should seek information about other causes, such as drugs, vascular disease, endocrine dysfunction, depression, and alcohol consumption.” Taken together, the erectile dysfunction article only supports a correlation, not causation, between erectile dysfunction and diabetes for an age range of men that is outside of the Veteran’s age at the time of his diagnosis of erectile dysfunction. The article also specifically instructs clinicians that they should not automatically assume that erectile dysfunction is caused by diabetes. For these reasons, the March 2015 private medical opinion and the accompanying article do not support the existence of a nexus between diabetes and the Veteran’s erectile dysfunction. However, as previously stated, the Board finds that the otherwise supports entitlement to service connection for erectile dysfunction. 4. Entitlement to service connection for left ear hearing loss Service connection will be presumed for certain chronic diseases, including bilateral hearing loss, if manifest to a compensable degree within one year after discharge from service. See 38 C.F.R. §§ 3.307, 3.309. Because there is no indication that the Veteran’s hearing loss was manifested within one year of service, service connection is not available on a presumptive basis. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies at 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Even if disabling loss is not demonstrated at separation, a veteran may establish service connection for a current hearing disability by submitting evidence that a current disability is causally related to service. See Hensley v. Brown, 5 Vet. App. 155, 160 (1993). Regarding the first element, the November 2013 VA audiological examination provides a current diagnosis of left ear hearing loss but not right ear hearing loss. Pure tone thresholds, in decibels, are as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 15 20 35 LEFT 15 25 50 55 65 Speech recognition ability using the Maryland CNC test is 100 percent in the right ear and 88 percent in the left ear. For the left ear, the evidence supports a current diagnosis of hearing loss, based on the Veteran’s Maryland CNC test and the pure tone threshold values at 3000 and 4000 Hertz. The examination does not support a current diagnosis of right ear hearing loss. The second element is also satisfied, in that the Veteran argues that his hearing loss is the result of his in-service experience as a pilot, when he had to start plane engines with the front windshield down. The nexus element is also satisfied. A November 2015 private medical opinion indicates “unilateral hearing loss since 1972” that is related to “a history of military noise exposure.” The examiner reports the following pure tone thresholds for the Veteran: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 20 30 45 LEFT 25 35 55 60 70 Maryland CNC test scores are 96 percent for the right ear 84 percent for the left ear. Based on OSHA data, the private examiner states that “the following amount of the veteran’s hearing loss may be attributed to factors other than his age”: HERTZ 500 1000 2000 3000 4000 RIGHT – 9 7 7 12 LEFT – 25 42 37 37 For the left ear at 2000 Hertz, the total shift in pure tone threshold independent of age is greater than the overall shift required to satisfy the criteria for a current hearing loss disability under 38 C.F.R. § 3.385. Giving the Veteran the benefit of the doubt, the Board finds that this table supports the existence of a nexus between service and left ear hearing loss. The Veteran is therefore entitled to prevail with respect to his claim of entitlement to service connection for left ear hearing loss. While the November 2015 private medical examination indicates a current diagnosis of hearing loss, the indicated data only supports the existence of a nexus between left ear hearing loss and service. Also, as already noted, the language of this opinion specifies that only “unilateral hearing loss” is related to military service. For these reasons, the November 2015 private medical examination does not by itself support entitlement to service connection for right ear hearing loss. However, as will be explained below, this examination does support entitlement to an addendum opinion. In concluding that the Veteran is entitled to service connection for left ear hearing loss, the Board has considered the November 2013 VA medical opinion. That opinion concludes that the Veteran’s left ear hearing loss is less likely than not related to service. The rationale is that his hearing was within normal limits when exiting service, despite certain rises in pure tone thresholds at 6000 Hertz during service. As the evidence is at least in equipoise, the Veteran is entitled to prevail with respect to his claim. 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55–56. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to consider all regulations that are potentially applicable through the assertions and issues raised in the record. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings.” Hart v. Mansfield, 21 Vet. App. 505 (2007). 5. Entitlement to an initial rating of 20 percent, but no greater, for diabetic polyneuropathy of the left lower extremity 6. Entitlement to an initial rating of 20 percent, but no greater, for diabetic polyneuropathy of the right lower extremity In February 2015, the RO granted service connection for diabetic polyneuropathy of the left and right lower extremities at initial ratings of 10 percent under Diagnostic Code 8521 from April 22, 2014. That is the date noted in a May 2014 DBQ filled out by a private physician (received 6/30/14) as the date that the Veteran was first diagnosed with diabetic polyneuropathy. See also April 2014 private medical record (received 12/11/12, page 11 of 98). The Veteran is appealing the rating aspect of the February 2015 decision. Because the claim is an initial claim, the Board will consider evidence of symptomatology from the date that the claim was filed. 38 C.F.R. § 3.400(o). Diagnostic Code 8521 provides compensation for paralysis of the external popliteal nerve (common peroneal). 38 C.F.R. § 4.124a. A 10 percent rating is provided for mild, incomplete paralysis. Id. A 20 percent rating is provided for moderate, incomplete paralysis. Id. A 30 percent rating is provided for severe, incomplete paralysis. Id. A 40 percent rating is provided for complete paralysis based on foot drop with slight drop of the first phalanges of all toes, inability to dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost, abduction of foot lost, adduction weakened, and anesthesia covers entire dorsum of foot and toes. Id. The term “incomplete paralysis,” with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the affected nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The ratings for the peripheral nerves are for unilateral involvement. Id. The words “slight,” “mild,” “moderate” and “severe” as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The evidence supports a rating of 20 percent for both lower extremities. In an April 2014 private EMG study, the Veteran states that he experiences “pain, numbnes[s] and tingling in both feet at the end of the day.” His private doctor states that the Veteran’s diabetic polyneuropathy “is consistent with a severe sensory neuropathy of the bilateral lower extremities that is commonly seen in patients with diabetes.” A May 2014 DBQ filled out by a different private physician indicates moderate constant pain, mild paresthesias and/or dysesthesias, and mild numbness for both lower extremities. The Veteran cannot “stand on [his] feet for prolonged lengths of time” because of his diabetic neuropathy. In considering the evidence as a whole, the existence of moderate constant pain with mild paresthesias, mild numbness, and the inability to stand on his feet for extended periods of time supports a rating of 20 percent based on the existence of moderate, incomplete paralysis. The Veteran argues that he is entitled to a higher rating because his April 2014 doctor states that the Veteran’s neuropathy is severe. See July 2016 VA Form 9; February 2015 notice of disagreement. However, the Veteran’s report of symptoms during the April 2014 study indicate mild symptoms that are only present at the end of the day, suggesting that his symptoms are not chronic. His May 2014 private doctor indicates symptoms that are at worst moderate. The May 2014 private examiner also states: “[S]evere sensory neuropathy of bilateral lower extremities commonly seen in diabetes.” However, as no individual symptom is described as worse than moderate, this statement by itself does not provide sufficient bases to support a finding of severe, incomplete paralysis. Also, as the statement is contained in a section specifically referencing the April 2014 EMG and is essentially identical to that doctor’s conclusion, it appears to be a partial quotation of the EMG study rather than an expression of current symptomatology. Taken together, the preponderance of the evidence is against the existence of severe, incomplete paralysis so as to support a rating of 30 percent. While the April 2014 doctor notes severe symptomatology, that characterization is inconsistent with the Veteran’s April 2014 lay report of symptomatology and the medical findings contained in the May 2014 DBQ. It follows that while the EMG findings themselves may be “consistent with a severe neuropathy,” the Veteran’s overall symptoms are actually of lesser severity than would be expected from the EMG findings alone. Also, the Veteran can still stand and walk, albeit for limited periods of time, the May 2014 private examiner characterizes his symptoms as no worse than moderate, and during his EMG study the Veteran indicates that his problems are only present at night. The preponderance of this evidence is against the existence of severe, incomplete paralysis so as to support a rating of 30 percent. The evidence does not support additional staged ratings for any time period on appeal. For no period would the Veteran be entitled to a higher rating under a different Diagnostic Code. REASONS FOR REMAND Entitlement to service connection for right ear hearing loss is remanded. In December 2013, the RO denied entitlement to service connection for bilateral hearing loss. With respect to the right ear, part of the rationale for that decision was that a November 2013 VA audiological examination did not indicate a current diagnosis of right ear hearing loss. Since that time, the Veteran has submitted two private audiograms indicating right ear hearing loss. See November 2015 private medical record. An addendum opinion is required that addresses this evidence. The Board has considered the June 2014 private medical opinion. This opinion states that the Veteran’s “sensorineural hearing loss of uncertain etiology [is] possibly due in part to previous noise exposure.” Unfortunately, “possibly” does not provide the level of certainty necessary to establish service connection. See Bostain v. West, 11 Vet. App. 124, 128 (1998); Warren v. Brown, 6 Vet. App. 4, 6 (1993). By itself, the June 2014 private medical opinion does not support entitlement to service connection for right ear hearing loss. The Board has also considered the March 2015 private medical opinion. This opinion states, in part: “His loss of hearing is also service connected. In review of his documents, one of the hearing test[s] appears to be in error as it is not consistent with the pattern of the other entire test and his current state.” This opinion does not indicate which ear or ears has a diagnosis of hearing loss and contains no accompanying rationale, supporting documents, or supporting medical evidence. By itself, the March 2015 private medical opinion does not support entitlement to service connection for bilateral hearing loss. The matter is REMANDED for the following action: 1. An examiner must provide the following medical opinions: (a.) Whether the Veteran has any current right ear hearing loss disorder; and (b.) Whether it is at least as likely as not (a 50 percent or better probability) that any current right ear hearing loss disorder was incurred in the Veteran’s service. In rendering these opinions, the examiner should consider the November 2015 private medical record. Whether to schedule the Veteran for an additional examination shall be left to the discretion of the examiner selected to provide the addendum opinion. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Cannon, Associate Counsel