Citation Nr: 18160909 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 15-24 864 DATE: December 28, 2018 ORDER Entitlement to an initial disability rating in excess of 30 percent for intramuscular hemangioma of the neck, is denied. Entitlement to an initial disability rating in excess of 20 percent for painful post-intramuscular hemangioma neck scars is denied. Entitlement to an initial compensable rating for chronic sinusitis is denied. REMANDED Entitlement to service connection for retention cyst, left maxillary sinus, is remanded. Entitlement to service connection for a bilateral ear condition, claimed as otitis media, is remanded. Entitlement to service connection for mycoplasma pneumonia is remanded. Entitlement to service connection for Epstein Barr virus (EBV) is remanded. Entitlement to service connection for infectious mononucleosis is remanded. Entitlement to an initial rating in excess of 10 percent disabling for left lower extremity (LLE) peripheral neuropathy is remanded. Entitlement to an initial rating in excess of 10 percent disabling for right lower extremity (RLE) peripheral neuropathy is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s intramuscular hemangioma is manifested by no more than three characteristics of disfigurement. 2. The Veteran’s painful post-intramuscular hemangioma neck scars are manifested by no more than four scars. 3. The Veteran’s chronic sinusitis is manifested by no more than one non-incapacitating episode per year. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent disabling for intramuscular hemangioma have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.118, Diagnostic Code (DC) 7800 (2018). 2. The criteria for an initial rating in excess of 20 percent disabling for painful post-intramuscular hemangioma neck scars have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.118, DC 7804 (2018). 3. The criteria for an initial compensable rating for chronic sinusitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.97, DC 6513 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1976 to June 1988. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1995). 1. Intramuscular Hemangioma and Neck Scar The Veteran filed a service connection claim for intramuscular hemangioma and submandibular cysts in March 2011. Those claims were granted in a March 2012 rating decision and assigned separate 30 percent evaluations effective March 2012. The service-connected intramuscular hemangioma was assigned a 30 percent evaluation pursuant to 38 C.F.R. § 4.118, DC 7800, on the basis of three characteristics of disfigurement. Additionally, the surgical neck scar related to the intramuscular hemangioma and the service-connected submandibular cysts were assigned a 30 percent evaluation pursuant to 38 C.F.R. § 4.118, DC 7804, on the basis of five or more painful scars. The Veteran has appealed the initial ratings. The Board notes that a subsequent April 2018 rating decision decreased the 30 percent rating based on painful scars to 20 percent. In this regard, the Agency of Original Jurisdiction (AOJ) noted that the March 2012 rating decision erroneously assigned a higher 30 percent rating based on five or more painful scars when the evidence of record clearly showed only four scars. The AOJ further noted that as the Veteran’s combined assigned ratings were being increased from 60 to 70 percent, the rating reduction for painful scars did not negatively impact his overall combined rating; thus, a proposed rating reduction action was not necessary. The Veteran underwent a VA examination in July 2011. Upon examination, the examiner noted the intramuscular hemangioma was characteristic of a lump present at the chin. The examiner also noted three submandibular cysts measuring 0.5 cm by 0.5 cm and circular in shape. The examiner noted the cysts were tender to palpation with adherence to the underlying structure, a soft texture and an elevated surface. The examiner further noted a neck scar measuring 5 cm by 0.3 cm which was painful on examination. No skin breakdown was found. Additionally, no inflammation or edema was present. The scar was noted as not disfiguring and did not limit motion. The scar was further found to adhere to the underlying tissue and was level on palpation. The scar texture was noted as normal and no hypo or hyper-pigmentation. Further, no functional limitation was noted due to the neck scar and the scar was not found disfiguring. In addition, the examiner noted that the scars were not indurated or inflexible with no underlying soft tissue loss or gross distortion or asymmetry of the forehead, eyes, eyelids, ears, nose, cheeks, lips or chin. The Veteran reported pain in his jaw noted which occurred while eating. At a December 2017 VA examination, the examiner noted a surgical neck scar and three cysts on the Veteran’s face. No other scars were noted. The scars were found to result in disfigurement of the face or neck. The neck scar was noted as a well healed linear superficial scar 4 cm long and 0.1 cm wide located in the submandibular region. No elevation, depression, adherence to the underlying tissue or missing underlying soft tissue was found. Additionally, the examiner noted no abnormal pigmentation or texture or gross distortion or asymmetry of facial features or visible or palpable tissue loss. The surgical scar was further noted as non-painful with no keloid. In addition, three distinct subcutaneous nodular lesions on the right side of the chin measuring 1 cm in diameter were noted. The Veteran reported a throbbing pain in his lesions resulting in difficulty chewing, eating. The Veteran further reported difficulty speaking certain words resulting in a speech impediment. The Veteran also reported facial redness which increased with physical activity. Following the December 2017 VA examination, in January 2018 a VA examination was requested to ascertain whether the Veteran’s reported speech and chewing impediments were etiologically related to his service-connected intramuscular hemangioma. The record shows that in February 2018, the Veteran cancelled his scheduled examination as he requested an examination at a different location. In a February 2018 letter, the AOJ requested the Veteran provide the location where he would like his VA examination to take place. A review of the claims file shows the Veteran has not responded to this request. Skin conditions are rated pursuant to 38 C.F.R. § 4.118. Under 38 C.F.R. § 4.118, scars are rated under DC 7800 (scars of the head, face, or neck or other disfigurement of the head, face or neck), 7801 (scars not of the head, face of neck, that are deep and nonlinear), 7802 (scars not of the head, face or neck that are superficial and nonlinear), and 7804 (scars that are unstable or painful). 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. 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. An 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. 38 C.F.R. § 4.118. The rating criteria contemplate 8 characteristics of disfigurement include the following: (1) scar 5 or more inches (13 or more cm) in length; (2) scar at least one-quarter inch (0.6 cm) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo-pigmented or hyper-pigmented in an area exceeding six square inches (39 sq. cm); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and, (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Id., Note 1. The characteristic(s) of disfigurement may be caused by one scar or by multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order ot assign that evaluation. Id., Note 5. DC 7804 provides a rating of 10 percent for one or two scars that are unstable or painful. A 20 percent evaluation is warranted for three or four scars that are unstable or painful. A 30 percent evaluation is warranted for five or six scars that are unstable or painful. 38 C.F.R. § 4.118. Initially, the Board notes that the Veteran’s service-connected intramuscular hemangioma and submandibular cysts are located on the Veteran’s face and neck. Therefore, ratings under DCs 7801 and 7802 which contemplate scars not located on the face or neck are not for application. The Board also notes that ratings for skin conditions unrelated to the Veteran’s service-connected intramuscular hemangioma and submandibular cysts can be found under DCs 7806 to 7833. As such, the Board will not consider those ratings. Turning to DC 7800, throughout the period on appeal, the Veteran’s intramuscular hemangioma has been characteristic of a lump. The cysts were found to adhere to the underlying structure and characteristic of a soft texture and an elevated surface contour. Additionally, the cysts were found to be 1 cm in diameter. No scar or cyst measured 5 inches or more. Additionally, the scar and cysts were not found to be manifested by abnormal texture, missing underlying soft tissue, or indurated and inflexible. Accordingly, throughout the period on appeal, the Veteran’s intramuscular hemangioma related scar and cysts were manifested by no more than three characteristics of disfigurement. In this regard, the Board recognizes the Veteran’s assertion that his face reddened with exertion. While his face in general may redden, his service-connected intramuscular hemangioma and submandibular cysts have specifically not been found to be manifested by abnormal pigmentation upon examination. Therefore, as the skin conditions were not manifested by four to five characteristics of disfigurement, a rating in excess of 30 percent is not warranted. Turning to DC 7804, during the entire period on appeal, the Veteran’s service-connected intramuscular hemangioma and submandibular cysts consisted of four scars (one surgical neck scar and three cysts). As such, pursuant to DC 7804, a rating in excess of 20 percent is not warranted as the Veteran has not been shown to have five or six scars. The Board further notes that pursuant to DC 7805, disabling effects not considered in a rating provided under DCs 7800-7804 are to be evaluated under an appropriate diagnostic code. In this regard, the Veteran was scheduled for a VA examination to determine the nature and etiology of his claimed speech and chewing impediment to determine whether they were etiologically related to his service-connected intramuscular hemangioma. However, the Veteran cancelled his scheduled VA examination and has not responded to requests to notify the AOJ which location he would want to report for an examination. The duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Under VA regulations, it is incumbent upon the Veteran to submit to a VA examination if he is applying for, or in receipt of, VA compensation or pension benefits. See Dusek v. Derwinski, 2 Vet. App. 519 (1992). When necessary or requested, the Veteran must cooperate with the VA in obtaining evidence. The Veteran’s failure to attend his VA examination constitutes a failure to cooperate in the development of his increased rating claim on appeal. Therefore, the Board is to adjudicate the claim based on the evidence of record. See 38 C.F.R. § 3.655. While the evidence of record shows the Veteran reported a speech and chewing impediment, those conditions have not been shown to be etiologically related to his service-connected intramuscular hemangioma. Absent a showing that his claimed residuals are etiologically related, separate ratings pursuant to DC 7805 are not for application. In sum, the Board finds that the preponderance of the evidence is against an initial rating in excess of 30 percent disabling for disfigurement of the face and neck. In addition, the preponderance of the evidence is against an initial rating in excess of 20 percent for painful scars. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.130; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Lastly, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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). 2. Sinusitis The Veteran filed a service connection claim for chronic sinusitis in March 2011. That claim was granted in a March 2012 rating decision and assigned a non-compensable evaluation pursuant to 38 C.F.R. § 4.97, effective March 2012. The Veteran has appealed the initial rating. Since filing his claim, the Veteran underwent a VA examination in July 2011. The Veteran reported that his chronic sinusitis existed since August 1982. He also reported that his sinus problems were constant. He denied any incapacitating episodes. Additionally, the examiner noted no incapacitating episodes reported in the past 12-months. The Veteran did report that sinusitis was symptomatic of headaches, interference with breathing through the nose, purulent discharge, hoarseness of voice and pain with episodes requiring antibiotic treatment lasting 4-6 weeks. The Veteran denied any crusting. In addition, the Veteran asserted that his sinus condition resulted in bad breath, snoring, post nasal drip and dizziness. Upon examination, the examiner noted sinusitis present at frontal sinus bilaterally and left maxillary sinus. No purulent discharge was observed. An April 2012 letter from the Veteran’s physician noted treatment for sinusitis in February 1995, October and November 1996, February 1999 and April 2011. At a December 2017 VA examination, the Veteran reported daily nasal congestion, post nasal drip, cough productive of yellow mucous, and frequent sinus headaches. The examiner noted symptoms of episodes of sinusitis, headaches and purulent discharge. The Veteran also reported 1 non-incapacitating episode in the past 12-months and denied any incapacitating episodes. Upon examination, the examiner also noted white discharge in both nostrils. No crusting, polyps, ulcerations were found. No sinus tenderness was observed. The degree of disability was found to be mild. Under the General Rating Formula for Sinusitis, a noncompensable rating is warranted for sinusitis that is detected by X-ray only. A 10 percent rating is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is assigned for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A Note to the General Rating Formula for Sinusitis provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97. After a review of the evidence of record, the Board finds that an initial compensable rating is not warranted. The Board recognizes that during his July 2011 VA examination, the Veteran reported sinus problems that were constant with symptoms of headaches and purulent discharge. The Board also notes that the July 2011 examination report shows the Veteran denied any incapacitating episodes, and noted “0” for reported non-incapacitating episodes. In this regard, an April 2012 letter from the Veteran’s treating physician noted treatment for sinusitis once in 1995, twice in 1996, once in 1999 and once in 2011. Additionally, during the December 2017 VA examination, the Veteran specifically reported having had only one non-incapacitating episode in the past 12-month period. As such, the evidence of record does not support a finding of three to six non-incapacitating episodes of sinusitis per year. The Board recognizes the Veteran’s April 2012 NOD in which he asserted “extensive incapacitating conditions for over 3 months straight in 2011.” However, as noted by the Veteran, the noted conditions included repeated respiratory infections, pneumonia, and other non-sinusitis conditions. Importantly, as noted above, during both the July 2011 and December 2017 VA examinations, the Veteran specifically reported, at most, one non-incapacitating episode in the past year; a finding supported by the April 2012 letter showing intermittent treatment for sinusitis between 1995 and 2011. Accordingly, the Board finds that the preponderance of the evidence is against an initial compensable rating for chronic sinusitis. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.130; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Lastly, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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 1. Retention Cyst, Left Maxillary Sinus The Veteran asserts entitlement to service connection for a retention cyst located in the left maxillary sinus. Specifically, the Veteran asserts that he was diagnosed with a left maxillary retention cyst during service and that this condition was currently present. Initially, the Board notes that the Veteran’s service treatment records (STRs) include an April 1987 MRI study revealing a retention cyst in the left maxillary sinus. Post service medical records include a March 2011 MRI study which revealed extensive sinus disease as well as extensive fluid in the mastoid air cells bilaterally. Additionally, moderate mucosal disease was noted in both maxillary and ethmoid sinuses. The Veteran underwent a VA sinus examination in July 2011. The Veteran reported that he had a diagnosed sinus cyst condition since 1986. Upon examination, the examiner noted no nasal obstruction or nasal polyps. The examiner did note sinusitis present at the bilateral front and left maxillary sinuses with tenderness. The Veteran further underwent a VA eye examination in July 2011. The Veteran reported being diagnosed with an injury to his left orbit secondary to trauma sustained in November 1986. The Veteran also reported that a 1987 MRI and X-ray study showed a fracture and cyst on the maxillary. No left orbit injury (i.e. cyst) diagnosis was rendered as no pathology was found. The examiner also opined that traumatic injury to the bone may cause cyst formation and that the maxillary cyst formation was at least as likely as not related to the left orbital cyst documented in service. In a July 2011 addendum opinion, the examiner was asked to address the conflicting statements regarding a diagnosed maxillary cyst formation. In response the examiner stated that no cyst was found and that the statement regarding a maxillary cyst formation was based solely on the Veteran’s lay statements. The examiner further noted that there was no medical evidence in the “12 pages of the Veteran’s medical records” showing an X-ray or MRI study revealing a left orbital cyst. The examiner further noted that no such condition could not be visualized during the eye examination. The Board finds the July 2011 VA examination inadequate. First, the examiner’s negative nexus opinion is based in an inaccurate factual predicate; namely that the record was devoid of any medical evidence of a diagnosed cyst. As noted above, an April 1987 MRI study revealed a retention cyst in the left maxillary sinus. Second, the examiner noted that only 12 pages of the Veteran’s medical records were reviewed. In this regard, the claims file includes several hundred pages of medical records. As such, the VA examiner does not appear to have reviewed the Veteran’s entire claims file, including relevant medical records noting a diagnosed left maxillary cyst. VA’s duty to assist a claimant includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d)(1); 38 C.F.R. § 3.159(c)(4). The medical examination provided must be thorough and contemporaneous and consider prior medical examination and treatment. Green v. Derwinski, 1 Vet. App. 121 (1991). To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Additionally, a medical opinion that is unsupported and unexplained is purely speculative and does not provide the degree of certainty required for medical nexus evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Miller v. West, 11 Vet. App. 345, 348 (1998) (medical opinions must be supported by clinical findings in the record; bare conclusions, even those made by medical professionals, which are not accompanied by a factual predicate in the record, are not probative medical opinions). Accordingly, a new VA examination is necessary to properly adjudicate this issue on appeal. 2. Bilateral Ear Condition The Veteran asserts entitlement to service connection for a bilateral ear condition, claimed as otitis media. The Veteran’s STRs document treatment for ear conditions including otitis externa in June 1977 and August 1978. In July 1977, the Veteran was diagnosed with eustachitis. Post service medical records include a February 2011 CT scan revealing a diagnosis for bilateral mastoiditis. The CT scan was also noted to reveal some granulation tissue in both middle air cavities consistent with chronic otitis media. A February 2011 letter from Dr. MS noted the Veteran had severe otitis in the right ear and chronic otitis in the left. In March 2011, the Veteran underwent another CT scan which revealed a diagnosis for bilateral mastoiditis. Additionally, in March 2011, the Veteran was diagnosed with acute mucoid otitis media via a CT scan. Finally, a March 2011 ENT record shows the Veteran was assessed with an eustachian tube dysfunction associated with massive allergies. The Veteran underwent a VA examination in July 2011. The Veteran reported being diagnosed with otitis media and otitis externa and that the conditions existed since 1977. The Veteran further reported that his bilateral ear conditions were due to a frostbite injury sustained while serving on an ice breaker. In addition, the Veteran reported a history of ear infections bilaterally with occurrences once per year with each episode lasting two weeks. Other reported symptoms included dizziness, vertigo, ear pain, ear pruritus, and a staggering and cerebellar gait. Upon examination, the examiner noted normal external canal, mastoid and tympanic membrane. Additionally, no auricle deformity, aural polyps, middle ear infection or effusion was found. The examiner further noted no ear related cranial nerve condition or bone loss of the skill, disturbance of balance or staggering or cerebellar gait. Based upon the examination, the examiner did not provide an etiological opinion as the Veteran was not currently found to have a diagnosis for acute bilateral otitis media, otitis externa, or any related residuals. The Board finds the July 2011 VA examination inadequate. As noted above, the medical evidence of record includes diagnoses for chronic otitis media, bilateral mastoiditis and an eustachian tube dysfunction several months prior to the July 2011 examination, including diagnoses after filing his claim in March 2011. For VA purposes, a current disability exists when a claimant has a disability at the time a claim is filed or at some point during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he/she files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim). However, the VA examiner did not address that evidence. The Board finds this omission especially important in light of the Veteran’s lay statements that he had a history of ear infections with occurrences once per year with each episode lasting two weeks. As the record shows the Veteran was diagnosed with bilateral ear conditions during the pendency of his claim, the Board finds that a new VA examination is necessary to adequately determine the nature and etiology of any diagnosed bilateral ear condition. Barr, 21 Vet. App. at 312. 3. Mycoplasma Pneumonia, EBV and Infectious Mononucleosis The Veteran asserts entitlement to service connection for mycoplasma pneumonia, EBV and infectious mononucleosis. Initially, the Board notes the Veteran’s STRs show treatment for the above claimed conditions. Of significance, the Board notes a January 1987 medical record noting a past medical history for a number of upper respiratory infections, mononucleosis, and four episodes of pneumonia. A May 1987 STR noted a possible chronic EBV infection, and alternatively noted “seriously doubt chronic EBV infection.” The record also noted the Veteran underwent an evaluation in 1982 due to symptoms of chronic fatigue, recurrent fever, myalgias and headaches. At that time, chronic allergic rhinitis was found to be the most likely cause but chronic EBV was also considered due to previous infections in 1974, 1980 and 1982. Finally, a November 1987 STR noted a diagnosis for infectious mononucleosis only partially cleared up from 1974. The clinician also noted that the chronic infectious mononucleosis versus CMV infection should be considered. In addition, the clinician was further noted to have a history of EBV infection which could also have a profound effect on the Veteran’s immune system. Post service medical records include a March 2011 private medical record noting a history of chronic infection with mycoplasma. Another March 2011 private medical record noted the post-operative course of mycoplasma pneumonia and that the Veteran appeared to be potentially colonized due to the history of recurrent mycoplasma pneumonia infections. An April 2012 letter from the Veteran’s physician noted treatment for mycoplasma infection in January, February, April and June 2011, and January 2012. A May 2012 VA ENT record noted a past medical history for EBV infection. Finally, A July 2012 VA medical record noted a history of pneumonia in 1974 with recurrent mycoplasma and mononucleosis. Upon examination, the physician stated that it was unclear whether the Veteran had recurrent pneumonia. Instead, the physician found that it was more likely the Veteran has symptoms related to post-nasal drip. Immunoglobulins were noted as within normal limits. To date, the Veteran has not been provided with a VA examination with regard to these claimed conditions. As noted above, the STRs clearly show treatment for mycoplasma pneumonia, EBV and infectious mononucleosis. Additionally, the STRs appear to show that the conditions may be interrelated due to the possible effect EBV may have had on the Veteran’s immune system. Post-service medical record additionally shows treatment and/or a past medical history for the above claimed conditions. VA must provide a medical examination when there is evidence of (1) a current disability, (2) an in-service event, injury, or disease, (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for VA to make a decision. McClendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159 (c)(4)(i). The third prong, which requires evidence that the claimed disability or symptoms “may be” associated with the established event, is a low threshold. McClendon, 20 Vet. App. at 83. Accordingly, a remand in necessary to obtain a VA examination to determine the nature and etiology of the claimed mycoplasma pneumonia, EBV and infectious mononucleosis. 4. Bilateral Lower Extremity (BLE) peripheral neuropathy The Veteran asserts entitlement to an initial rating in excess of 10 percent for his service-connected RLE and LLE peripheral neuropathy. The Veteran initially underwent a VA examination in July 2011. In his July 2015, VA Form 9, the Veteran asserted that his BLE peripheral neuropathy had worsened. Thereafter, the Veteran underwent another VA examination in December 2017. The Veteran reported persistent BLE pain, tingling and intermittent numbness. He further reported difficulty walking due to impaired coordination. The Veteran’s BLE peripheral neuropathy was found symptomatic of moderate paresthesias and/or dysesthesias and moderate numbness. Sensory testing was significant to decreased lower leg/ankle and foot/toes. With regard to the affected nerves, the examiner only noted incomplete paralysis of the right external popliteal nerve, mild in severity. In January 2018, the DRO noted that the December 2017 examination report did not provide a response as to which nerve group was affected by the LLE peripheral neuropathy. In an addendum opinion, the examiner noted that only the right peroneal nerve was described in a June 2015 NCV and EMG study. As such, the examiner noted that it was not possible to specify what other nerves involving the BLE were involved without resorting to mere speculation. Therefore, the examiner noted she had marked “normal” for the LLE. As noted above, the Veteran reported a worsening BLE peripheral neuropathy condition in July 2015 and was provided a new VA examination to ascertain the current nature and severity of his condition in December 2017. However, the December 2017 VA examiner relied on a NCV and EMG study that predated the Veteran’s reports of a worsening condition. Additionally, despite the Veteran’s reports of similar symptomatology affecting the BLE, as well as the examiner’s similar testing results for both RLE and LLE, the Board finds that the reliance on a two-year old EMG study that apparently not indicative of the current level of severity was in error. At the very least, a new EMG nerve conduction study should have been conducted if the examiner was unable to make a determination without resorting to mere speculation. Accordingly, the Board finds that a remand is necessary to obtain a EMG nerve conduction study to determine the current nature and severity of his BLE peripheral neuropathy. Barr, 21 Vet. App. at 312. 5. TDIU Lastly, entitlement to a TDIU is inextricably intertwined with the Veteran’s claims on appeal. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran’s VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed left maxillary sinus cyst. The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that any diagnosed left maxillary sinus cyst is etiologically related to his period of service? All indicated studies should be completed, to include any imaging studies. The examiner should review pertinent documents in the Veteran’s claims file in connection with the examination. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 3. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed bilateral ear condition, to include otitis media, otitis externa, mastoiditis and eustachian tube dysfunction. The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed bilateral ear condition, including otitis media, otitis externa, mastoiditis and eustachian tube dysfunction, is etiologically related to his period of service? (b) Is it at least as likely as not (50 percent or greater probability) that any diagnosed bilateral ear condition, including otitis media, otitis externa, mastoiditis and eustachian tube dysfunction, was caused by a service-connected condition, to include chronic sinusitis? Please explain why or why not. (c) Is it at least as likely as not (50 percent or greater probability) that any diagnosed bilateral ear condition, including otitis media, otitis externa, mastoiditis and eustachian tube dysfunction, was permanently worsened beyond normal progression (aggravated) a service-connected condition, to include chronic sinusitis? Please explain why or why not. If the examiner finds that the disability was aggravated by the service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. The examiner should review pertinent documents in the Veteran’s claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 4. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed infectious condition, to include mycoplasma pneumonia, EBV, CMV and mononucleosis. The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that any diagnosed infectious condition, to include mycoplasma pneumonia, EBV, CMV and mononucleosis, is etiologically related to his period of service? (b) Is it at least as likely as not (50 percent or greater probability) that any diagnosed infectious condition, to include mycoplasma pneumonia, EBV, CMV and mononucleosis, was caused by a service-connected condition, to include chronic sinusitis? Please explain why or why not. (c) Is it at least as likely as not (50 percent or greater probability) that any diagnosed infectious condition, to include mycoplasma pneumonia, EBV, CMV and mononucleosis, was permanently worsened beyond normal progression (aggravated) by a service-connected condition, to include chronic sinusitis? Please explain why or why not. If the examiner finds that the disability was aggravated by the service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. The examiner should review pertinent documents in the Veteran’s claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified 5. Then, schedule the Veteran for an examination by an appropriate examiner to determine the current nature and severity of his service-connected BLE peripheral neuropathy. The examiner should review pertinent documents in the Veteran’s claims file and this Remand in connection with the examination. All indicated studies should be completed, including a EMG nerve conduction study, and all pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. 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. 6. Thereafter, the RO should readjudicate the claims on appeal, to include the claim for a TDIU. K. A. KENNERLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Lamb, Associate Counsel