Citation Nr: 1807011 Decision Date: 02/02/18 Archive Date: 02/14/18 DOCKET NO. 07-31 306 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for frontal sinus osteoma. 2. Entitlement to service connection for head trauma. 3. Entitlement to service connection for headaches. 4. Entitlement to service connection for chronic sinusitis/rhinitis. 5. Entitlement to service connection for gastrointestinal reflux disorder (GERD). 6. Entitlement to service connection for blisters on feet and swollen feet. 7. Entitlement to service connection for a bilateral shoulder disorder. 8. Entitlement to service connection for a sliced big toe. 9. Entitlement to service connection for gastritis. 10. Entitlement to service connection for gastric carcinoid tumors. 11. Entitlement to service connection for a bilateral shin condition. 12. Entitlement to service connection for heart disease. 13. Entitlement to service connection for injuries to the pharynx/larynx. 14. Entitlement to service connection for a bilateral elbow disability. 15. Entitlement to service connection for injury to the ribs. 16. Entitlement to service connection for septoplasty. 17. Entitlement to service connection for achalasia. 18. Entitlement to service connection for chondrocalcinosis of the right knee. 19. Entitlement to service connection for left cervical/sciatica radiculopathy. 20. Entitlement to service connection for degenerative disc disease of the cervical spine. 21. Entitlement to service connection for a neck tumor/cyst. 22. Entitlement to a rating in excess of 10 percent for tinnitus. 23. Entitlement to service connection for a lung disorder, due to asbestos exposure. 24. Entitlement to service connection for an acquired psychiatric disorder, to include depression, anxiety disorder, and posttraumatic stress disorder (PTSD), and to include as secondary to a lung disorder or to sleep apnea. 25. Entitlement to service connection for sleep apnea. 26. Entitlement to service connection for a lumbar spine disability. 27. Entitlement to service connection for left lower extremity radiculopathy, to include as secondary to a lumbar spine disability. 28. Entitlement to service connection for renal cell carcinoma, to include as secondary to asbestos exposure. 29. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder. 30. Entitlement to a compensable rating for bilateral hearing loss. 31. Entitlement to a compensable rating for folliculitis. 32. Entitlement to a compensable rating for tinea pedis. 33. Entitlement to a rating in excess of 10 percent for a left ankle disability. 34. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Mary E. Rude, Counsel INTRODUCTION The Veteran served on active duty from March 1975 to April 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2006 and May 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The case was remanded in September 2015 in order to afford the Veteran a hearing before a Veterans Law Judge. The Veteran attended a Board hearing in August 2017. The issues of entitlement to service connection for a lung disorder, sleep apnea, lumbar spine disability, left lower extremity radiculopathy, and renal cell carcinoma; to increased ratings for bilateral hearing loss, folliculitis, and a left ankle disability; to a TDIU, and whether new and material evidence has been received to reopen a claim of entitlement to service connection for hypertension are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. At the August 2017 Board hearing, the Veteran withdrew his appeal concerning the claims of entitlement to service connection for frontal sinus osteoma, head trauma, headaches, chronic sinusitis/rhinitis, GERD, left cervical/sciatica radiculopathy, blisters on feet and swollen feet, a bilateral shoulder disability, a sliced big toe, gastritis, gastric carcinoid tumors, a bilateral shin condition, heart disease, injuries to the pharynx/larynx, a bilateral elbow disability, injury to the ribs, septoplasty, achalasia, chondrocalcinosis of the right knee, degenerative disc disease of the cervical spine, and a neck tumor/cyst, and entitlement to a rating in excess of 10 percent for tinnitus. 2. The Veteran does not currently have any symptoms of tinea pedis, including any scars or symptoms which affect at least 5 percent of the entire body or the exposed areas of the body, and he does not require intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for at least 6 weeks out of the last 12-month period. 3. The Veteran has reported experiencing a traumatic car accident in service which is supported by credible corroborating evidence. Competent medical evidence has found that he has a current diagnosis from a VA psychiatrist of PTSD which is etiologically related to that in-service traumatic event. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal regarding entitlement to service connection for frontal sinus osteoma, head trauma, headaches, chronic sinusitis/rhinitis, GERD, left cervical/sciatica radiculopathy, blisters on feet and swollen feet, a bilateral shoulder disability, a sliced big toe, gastritis, gastric carcinoid tumors, a bilateral shin condition, heart disease, injuries to the pharynx/larynx, a bilateral elbow disability, injury to the ribs, septoplasty, achalasia, chondrocalcinosis of the right knee, degenerative disc disease of the cervical spine, and a neck tumor/cyst, and entitlement to a rating in excess of 10 percent for tinnitus have been met. 38 U.S.C. § 7105(b)(2) (2012); 38 C.F.R. §§ 20.202, 20.204 (2017). 2. The criteria for a compensable evaluation for tinea pedis have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.2, 4.3, 4.7, 4.118, Diagnostic Codes 7806, 7813 (2017). 3. The criteria for entitlement to service connection for PTSD are met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawal A substantive appeal may be withdrawn in writing, except for appeals withdrawn on the record at a hearing, at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b). Withdrawal may be made by the appellant or by an authorized representative. 38 C.F.R. § 20.204(c). In October 2016 correspondence and at the August 2017 Board hearing, the Veteran requested that his claims of entitlement to service connection for frontal sinus osteoma, head trauma, headaches, chronic sinusitis/rhinitis, GERD, left cervical/sciatica radiculopathy, blisters on feet and swollen feet, a bilateral shoulder disability, a sliced big toe, gastritis, gastric carcinoid tumors, a bilateral shin condition, heart disease, injuries to the pharynx/larynx, a bilateral elbow disability, injury to the ribs, septoplasty, achalasia, chondrocalcinosis of the right knee, degenerative disc disease of the cervical spine, a neck tumor/cyst, and entitlement to a rating in excess of 10 percent for tinnitus be withdrawn. Therefore, there remains no allegation of errors of fact or law for appellate consideration with regards to these matters. Accordingly, the Board does not have jurisdiction to review the appeal of the issues, and they must be dismissed. Acquired Psychiatric Disorder The Veteran contends that he has an acquired psychiatric disorder which was either caused by events during his active duty service or is secondary to a lung disorder or sleep apnea. The Veteran stated at the August 2017 hearing that he had been diagnosed with depression and anxiety disorder in 2005. He said that he became anxious after his breathing problems worsened. He also stated that he was bullied and got into a fight in service, which could be related to his problems, and that the accidents he was in made him "edgy." In written correspondence, he has stated that his psychiatric disorder is related to the multiple motor vehicle accidents he experienced while on active duty. Another submitted statement from the Veteran's sister indicated that after his car accident, he became "sad and confused." The Veteran's brother submitted a letter stating that the Veteran was in a serious car accident in service and became depressed after that. In a separate letter, he wrote that the Veteran was very nervous and anxious when he got out of the Army. The Veteran's sister submitted a letter stating that the Veteran started having psychological problems in service, and that after service he had problems with alcohol and relationships. An October 2010 letter from the Veteran's ex-wife stated that she was married to the Veteran in 1995 and remembered him having nightmares. 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. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptomatology and an in-service stressor; and credible supporting evidence that the claimed in-service stressor actually occurred. If VA determines either that a veteran did not engage in combat with the enemy, the record must contain credible supporting evidence that corroborates the veteran's statements. Moreau v. Brown, 9 Vet. App. 389, 396 (1996). Applying the regulations discussed above to the current case, the Board finds that the Veteran has a current diagnosis of PTSD from a VA psychiatrist, which is related to a corroborated in-service traumatic event. The Veteran's private and VA treatment records show that he has been diagnosed with anxiety, depressive disorder, panic disorder, and PTSD. The Veteran attended a VA examination in February 2006 and was diagnosed with depressive disorder and panic disorder. VA psychiatrist H.P. wrote in an August 2012 letter that he had been treating the Veteran for mood disorder and PTSD since 2011. The Veteran's VA treatment records show that in October 2011, psychiatrist H.P. evaluated the Veteran and discussed his reports of having a bad car accident in service, which caused nightmares, sweating, flashbacks, hyperstartle response, and avoidance of crowds. The psychiatrist diagnosed the Veteran with anxiety attacks and PTSD. The Veteran's subsequent VA treatment records show continuing treatment for PTSD, with continuing notations of nightmares related to the accident in service. A November 2017 letter from social worker J.T. stated that the Veteran had been receiving treatment for depression and PTSD and that the Veteran reported having symptoms of PTSD stemming from two automobile accidents and an assault that occurred in service. He wrote that the Veteran reported having nightmares due to the past accidents. The Veteran's service personnel records do note that he was in a car accident in 1976. The Board finds that the October 2011 psychiatric evaluation and subsequent treatment records from Dr. H.P. provide adequate medical evidence to establish that the Veteran has a current diagnosis of PTSD, and it is related by competent medical evidence to sufficiently corroborated in-service events. The Veteran's service personnel records do note that he was in a car accident in 1976, and his brother has also written that he remembers the Veteran being in a serious car accident in service. This adequately corroborates the Veteran's assertions of having been in a traumatic car accident in service, and a VA psychiatrist found that this stressor was of adequate severity to support a diagnosis of PTSD. In sum, given the evidence outlined above, the Board finds that the Veteran has a current psychiatric diagnosis of PTSD, which has been linked by competent medical evidence to an event in service which is supported by corroborating evidence. As such, entitlement to service connection is granted. Tinea Pedis The Veteran was granted entitlement to service connection for tinea pedis in a September 2011 Board decision. In an October 2011 rating decision, he was granted a noncompensable (0 percent evaluation), effective September 26, 2003. In May 2013, the Veteran requested an increased rating for his tinea pedis. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is or primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection to consider the appropriateness of a "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 199, 126 (1999); see also Hart v. Mansfield, 21 Vet.App. 505 (2007). Disabilities of the skin are rated under 38 C.F.R. § 4.118. Under Diagnostic Code 7813, dermatophytosis (ringworm: of body, tinea corporis; of head, tinea capitis; of feet, tinea pedis; of beard area, tinea barbae; of nails, tinea unguium; of inguinal area, tinea cruris) is rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, 7805), or dermatitis (Diagnostic Code 7806) depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7813. There is no evidence indicating that the Veteran has ever had scarring due to his tinea pedis, so the Veteran's disability is most closely analogous to dermatitis under Diagnostic Code 7806. Under Diagnostic Code 7806, a 10 percent rating is warranted for 5 to 20 percent of the entire body or exposed areas affected, or there is intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than 6 weeks during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. The Board has reviewed all of the evidence of record, but finds that there is no evidence indicating that a compensable rating for tinea pedis is warranted. The Veteran stated at the August 2017 Board hearing that his tinea pedis has been in remission, that he did not have any active symptoms, and that he had not had any for a while, possibly since 2005. He stated that he did get a cream for it from VA. At a May 2013 VA examination, the examiner stated that the Veteran had a diagnosis of tinea pedis, but upon physical examination, found no evidence of tinea pedis. The Veteran only had slightly thickened skin consistent with dermatitis overlying the bilateral lateral malleolus. The Veteran's VA treatment records do not show any diagnoses or treatment for tinea pedis. The medications he has been prescribed by VA, including dermatological cream and oral medications, were prescribed for treatment of folliculitis and neurodermatitis on his arms and legs. The issue of entitlement to an increased rating for folliculitis is a separate issue that is addressed in the remand below. The Board therefore finds that there is absolutely no evidence indicating that the Veteran's tinea pedis has had any manifestations whatsoever during the period on appeal. He has also not asserted that he has, and he clearly stated at the August 2017 Board hearing that he did not have any active symptoms since 2005, which is well before the Veteran submitted the current claim for an increased rating in 2013. This assertion is uncontradicted by the Veteran's medical records, which show no treatment for tinea pedis, as well as the findings of the May 2013 VA examiner. While the Veteran has stated that he uses a topical cream, his medical records clearly show that this was prescribed for the treatment of other skin conditions, diagnosed as folliculitis and dermatitis, which affect different parts of his body. Even if the Veteran did use the topical medication for tinea pedis on his feet as well, the use of only topical therapy is specifically listed in the rating criteria as allowing only a noncompensable evaluation. Id. In sum, there is no basis for assignment of a compensable rating for tinea pedis. In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. 38 U.S.C. § 5107(b). ORDER The appeal concerning the claim of entitlement to service connection for frontal sinus osteoma is dismissed. The appeal concerning the claim of entitlement to service connection for head trauma is dismissed. The appeal concerning the claim of entitlement to service connection for headaches is dismissed. The appeal concerning the claim of entitlement to service connection for chronic sinusitis/rhinitis is dismissed. The appeal concerning the claim of entitlement to service connection for GERD is dismissed. The appeal concerning the claim of entitlement to service connection for left cervical/sciatica radiculopathy is dismissed. The appeal concerning the claim of entitlement to service connection for blisters on feet and swollen feet is dismissed. The appeal concerning the claim of entitlement to service connection for a bilateral shoulder disability is dismissed. The appeal concerning the claim of entitlement to service connection for a sliced big toe is dismissed. The appeal concerning the claim of entitlement to service connection for gastritis is dismissed. The appeal concerning the claim of entitlement to service connection for gastric carcinoid tumors is dismissed. The appeal concerning the claim of entitlement to service connection for a bilateral shin condition is dismissed. The appeal concerning the claim of entitlement to service connection for heart disease is dismissed. The appeal concerning the claim of entitlement to service connection for injuries to the pharynx/larynx is dismissed. The appeal concerning the claim of entitlement to service connection for a bilateral elbow disability is dismissed. The appeal concerning the claim of entitlement to service connection for injury to the ribs is dismissed. The appeal concerning the claim of entitlement to service connection for septoplasty is dismissed. The appeal concerning the claim of entitlement to service connection for achalasia is dismissed. The appeal concerning the claim of entitlement to service connection for chondrocalcinosis of the right knee is dismissed. The appeal concerning the claim of entitlement to service connection for degenerative disc disease of the cervical spine is dismissed. The appeal concerning the claim of entitlement to service connection for a neck tumor/cyst is dismissed. The appeal concerning the claim of entitlement to a rating in excess of 10 percent for tinnitus is dismissed. Entitlement to service connection for PTSD is granted. Entitlement to a compensable rating for tinea pedis is denied. REMAND Lung Disorder The Veteran contends that he has asbestosis, chronic obstructive pulmonary disorder (COPD), or other lung disorder that is related to asbestos exposure in service. The Veteran testified at the August 2017 Board hearing that he believed his lungs were affected by exposure to asbestos in service. He stated that in 1980 he was diagnosed with bronchitis and chronic cough and in 1991 he was diagnosed with asthma or COPD. He said that he did not have a respiratory condition in service, and that he currently uses an inhaler and received treatment from private doctors. In a November 2017 statement, A.C. wrote that she had been living with the Veteran in 1980 and remembered that he was admitted to the hospital in 1980 for shortness of breath and bronchitis. The Veteran's private treatment records show that he has visited many different treatment providers and had numerous complaints of shortness of breath, for which he has received a great variety of findings and diagnoses. A March 2003 chest X-ray showed increased markings left lower lung, and a December 2003 pulmonary testing found mild obstruction to air flow. March 2010 pulmonary function testing found mild restrictive ventilatory defect. In October 2010, the Veteran's physician noted a possible relationship between the Veteran's sleep apnea and his shortness of breath and that his dyspnea could be caused by anxiety. A January 2010 CT scan of the chest found no focal infiltrate or evidence of active interstitial lung disease, but mild atelectasis was noted. A June 2010 chest X-ray showed a likely scar at the left lung base, and a September 2010 lung perfusion test found small subsegmental perfusion changes that were suggestive of obstructive airway disease. Numerous chest X-rays taken in 2010, 2011, and 2012 were normal, but in September 2011, the Veteran complained of chest pain, and a chest X-ray found poorly defined opacity in the retrocardiac region of the left lower lobe. The Veteran was diagnosed with COPD by private physician F.G. in 2012 treatment records. He also received treatment in June 2012 from another physician for COPD. In June and August 2013, he was diagnosed with reactive airway disease. The Veteran's private physician S.R.S. has diagnosed his breathing disorders as asthma. At a December 2003 VA examination, the Veteran reported being a mechanic in service and working with brakes and clutches, which used asbestos. The examiner acknowledged that "it seems that there was some risk" for asbestos exposure. The Veteran reported having chronic cough and dyspnea on exertion. The examiner noted that there was a question regarding whether the Veteran actually had asbestosis, as he did not present a condition very suggestive of asbestosis. A letter was received from private physician J.P. stating that the Veteran had occupational exposure to asbestos from 1978 to 1990, which led to radiographic changes consistent with pulmonary asbestosis and asbestos related pleural disease. He cited the March 2003 chest radiograph as evidence that the Veteran had pleural plaques consistent with asbestosis. The Board finds that the current evidence of record does indicate that the Veteran has some sort of respiratory disorder, although he has received varying diagnoses. Private physician J.P has also written that the Veteran's respiratory disorder is likely related to asbestos exposure, although that exposure included many years of occupational asbestos exposure in his civilian employment, and not exposure during the Veteran's service from 1975 to 1977. A VA examination has not yet found an actual diagnosis for the Veteran, nor has a VA medical opinion on the etiology of his respiratory symptoms been obtained. This issue is therefore remanded in order to afford the Veteran with a thorough examination, including all relevant pulmonary testing, to fully address the nature and etiology of any current respiratory disorder, including its possible relationship to asbestos exposure, sleep apnea, or a psychiatric disorder Sleep Apnea The Veteran contends that his sleep apnea had its onset during his active duty service. At the August 2017 Board hearing, the Veteran stated that he was diagnosed with sleep apnea in 2001 or 2005. He said that in service he had "snoring and sometimes catching my breath," and that after he got out of service, his symptoms became worse, causing him to wake up and be unable to breathe. The Veteran has also submitted correspondence asserting that he suffered head trauma from his car accidents in service that resulted in his sleep apnea. The Veteran's partner J.M. wrote in October 2017 that the Veteran snores every night and gasps for breath, and that he had this problem ever since she had known him. The Veteran's brother submitted a letter stating that the Veteran was in a serious car accident in service and that during and after his military service, the Veteran had loss of breath and dizziness. The Veteran's brother also wrote in August 2017 that his bedroom was next to the Veteran's when he got out of the Army, and he was awakened by his loud snoring and choking, and the Veteran would toss and turn and be sleepy during the day. The Veteran's private medical records show that he was diagnosed with obstructive sleep apnea in December 2003. The December 2003 VA examiner found that the Veteran had a current diagnosis of sleep apnea, but that it was not service-related, and could be connected to his respiratory problems. Because the December 2003 VA examiner raised the possibility that the Veteran's sleep apnea could be related to his respiratory problems, and the issue of entitlement to service connection for a lung disorder is also being remanded, this issue is intertwined, and the question of secondary service connection must be deferred until the underlying issue can be addressed. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Additionally, the December 2003 VA examiner provided no rationale for his finding regarding direct service connection for sleep apnea, and therefore a new and adequate medical opinion must be obtained regarding this issue. Lumbar Spine Disability and Left Lower Extremity Radiculopathy The Veteran also claims entitlement to service connection for a lumbar spine disability caused by injuries in service. The Veteran testified in August 2017 that he had injured his back in boot camp when he was carrying a heavy box and his ankle gave out, causing him to fall on his back. He stated that although he was primarily treated for his ankle injury, he also injured his back at that time, and that he further injured his back slipping in the snow and in car accidents later in service. He stated that he self-medicated his back until 2008, when he began to receive treatment from VA, and then began seeing a private doctor in 2010 or 2011. He stated that his lower extremity tingling and pain started after his motor vehicle accident in 1975 or 1977. A September 2010 letter from military colleague B.R. stated that he remembered the Veteran being in a serious vehicle accident and complaining of back pain afterwards. A letter from the Veteran's sister states that the Veteran began having back problems after his in-service car accident. The Veteran's personnel records do note that he was in a car accident in 1976. The Veteran's private treatment records show that in April 1990, the Veteran reported low back pain that radiated to his abdomen. The Veteran's more recent VA treatment records show treatment for lower back pain, diagnosed as lumbar spine facet arthropathy, lumbar spondylosis, degenerative disc disease, and degenerative joint disease, with associated left lower extremity radiculopathy. An October 2012 letter from Dr. B.A. stated that the Veteran reported developing back pain symptoms years ago while stationed at a military base in Germany. The Board therefore finds that there is evidence that the Veteran experienced a possible injury to his lumbar spine in service, and he has a current diagnosis of a lumbar spine disability. As no VA examination has yet been held, this issue is therefore remanded so that a VA examination can be obtained to determine the likely etiology of any current lumbar spine disorder. Private treatment records also show that the Veteran has been diagnosed with lumbar radiculopathy, and he has complained of pain radiating into his left leg. The issue of entitlement to service connection for left lower extremity radiculopathy is clearly intertwined with the lumbar spine claim, and a decision on this issue must be deferred until the underlying service connection question is adjudicated. See id. Renal Cell Carcinoma The Veteran stated in August 2017 that he believed that his renal cell carcinoma was due to asbestos exposure in service. He stated that he worked with brake pads and clutches which caused asbestos exposure. He also said that he may have been exposed to asbestos after service while working in construction. The Veteran said that he had been diagnosed with renal cell carcinoma in 1990 and had a mass in his kidney removed. The Veteran's private treatment records show that a March 1990 CT of the abdomen found a renal mass. He was diagnosed with renal cell carcinoma, and in June 1990, the Veteran underwent a left radical nephrectomy. The postoperative recovery was uneventful. The December 2003 VA examiner noted that the Veteran previously had renal cell carcinoma with left nephrectomy, but with no known recurrence. At a January 2006 VA examination, the examiner stated that the Veteran's renal cell carcinoma was treated in 1991, and as far as he could determine, this had not been a further problem or recurrence. A letter was submitted from private physician J.P. stating that the Veteran's occupational exposure to asbestos fiber inhalation and ingestion from 1978 to 1990 had led to the excision of his left kidney in June 1990, which had findings consistent with renal cell carcinoma. Although this letter does provide medical evidence that the Veteran's renal cell carcinoma was caused by exposure to asbestos, the examiner discussed only the Veteran's post-service asbestos exposure, and not any exposure caused during service. The Board therefore remands this issue in order to obtain a medical opinion regarding whether the Veteran's in-service asbestos exposure led to his later development of renal cell carcinoma. The Board notes that even if the Veteran is currently asymptomatic for renal cell carcinoma, removal of a kidney is assigned a minimum evaluation of 30 percent under 38 C.F.R. § 4.115b, Diagnostic Code 7500. It is therefore clearly established that the Veteran does have a current disability, despite the absence of active symptoms, as he has had his left kidney removed. Additionally, the Veteran's VA treatment records show that imaging performed in 2010 and 2012 shows that he has a right kidney cyst. While the Veteran's medical records currently do not indicate that he has been found to have renal cell carcinoma in the right kidney, the examiner should review all newly obtained medical records, and if his right kidney cyst was subsequently found to be cancerous, provide a medical opinion regarding the etiology of any right kidney disorder as well. New and Material Evidence for Hypertension In August 2017, the Veteran stated that he was diagnosed with hypertension in 1989 or 1990, but first started having problems with hypertension in 1980. He said that he was in the Army Reserves at that time, and that he believes hypertension was found on a service examination. A.C. submitted a November 2017 statement describing how she had been living with the Veteran in 1980 and remembered that he had applied for a job at that time but was told that his blood pressure was not under control. She wrote that he was treated in 1981 for high blood pressure. Although this issue has not been reopened, the record does not indicate that any attempt has yet been made to obtain the Veteran's Army Reserve records, which he asserts are relevant to the claim. Because the Veteran has identified service records which may be directly relevant to an issue necessary to substantiate the claim, this falls within VA's duty to assist the Veteran in obtaining records as provided in 38 C.F.R. § 3.159(c)(3), including in the case of an application to reopen a previously denied claim. 38 C.F.R. § 3.159(c) (2017). Hence, the AOJ should request from all appropriate sources any Army Reserve service treatment records. The Veteran is advised the he may also use this opportunity to attempt to obtain, or submit authorization for VA to obtain, any records related to his treatment of high blood pressure in the early 1980s. Folliculitis In May 2013, the Veteran requested an increased rating for his service-connected folliculitis. The Veteran stated in August 2017 that he treated his folliculitis with a daily cream. He stated that he has outbreaks that affect his legs, knees, ankle, head, scalp, buttocks, and back. The Veteran attended a VA examination in May 2013. The examiner noted that the Veteran constantly used a topical corticosteroid. He did not have any other treatments or procedures in the past 12 months. The examiner found that the Veteran did not currently have any skin condition, and marked that dermatitis affected less than 5 percent of the total body area. The examiner found no evidence of folliculitis. The Veteran only had slightly thickened skin consistent with lichen simplex chronicus (dermatitis) overlying the bilateral lateral malleolus. The Veteran is currently assigned a noncompensable (0 percent) rating for folliculitis under 38 C.F.R. § 4.118, Diagnostic Code 7806. This diagnostic code would allow for a higher rating if the Veteran were found to require intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. The Veteran's VA treatment records do, in fact, show that he has been prescribed such drugs. In 2014, the Veteran was prescribed hydroxyzine and Keflex, both of which are oral medications. The Board therefore finds that while the Veteran may not yet have been taking oral medication for his folliculitis at the time of the May 2013 VA examination, he was subsequently prescribed such medications. At the August 2017 Board hearing, the Veteran stated only that he was using a topical cream to treat his folliculitis. It is unclear to the Board if this is because the Veteran had stopped using the oral medication by 2017, or if he had declined to use the prescriptions offered to him by VA in 2014. The Board remands this issue in order to provide the Veteran with a new VA examination that will assess the current severity of his folliculitis and will discuss his use of any systemic therapy throughout the period of 2013 to the present. Bilateral Hearing Loss The Veteran stated at the August 2017 Board hearing that his hearing loss may have worsened since his last VA examination. He stated that he had been prescribed hearing aids by a private doctor around 2008. In addition, in December 2010, the Veteran submitted a letter to VA stating that his hearing had worsened. The Veteran has not attended a VA examination since July 2010. As the Veteran has asserted that his hearing has worsened, and the examination is now almost 8 years old, it likely does not represent an accurate picture of the current severity of his condition, and the issue must be remanded so that a new VA examination can be held. See Caffrey v. Brown, 6 Vet. App. 377 (1994). Left Ankle Disability The Veteran also contends that his service-connected left ankle disability warrants a rating higher than 10 percent. At the August 2017 Board hearing, the Veteran stated that he did not currently receive treatment for his ankle, but did use a brace and a cane. He stated that he took pain medication for his ankle and that it prevented him from walking very far or playing sports. He stated that the previous year he had attended physical therapy for his left ankle. The Veteran last attended a VA examination in May 2013. In September 2017, the Veteran attended a private evaluation of his left ankle. He reported that his left ankle pain had worsened over the past year, making standing and walking more difficult. The examiner performed range of motion testing, but did not consider painful motion or how range of motion was affected by other factors, such as incoordination and weakness, or after repetitive motion or during flare-ups. See 38 C.F.R. §§ 4.40 , 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). As the Veteran asserted in September 2017 that his left ankle disability has worsened in the past year, and range of motion testing with consideration of painful motion and other Deluca factors has not been completed since 2013, this issue is remanded in order to provide the Veteran with a new and adequate examination prior to adjudication. See Caffrey, 6 Vet. App. 377 (1994). TDIU A decision cannot be entered on the claim of entitlement to a TDIU until the remaining issues have been resolved. See Harris, 1 Vet. App. at 183. Accordingly, the case is REMANDED for the following action: 1. Verify the periods of the Veteran's service in the Army Reserve and any periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). 2. Obtain from the appropriate sources complete Army Reserve service treatment records for the Veteran. The AOJ must follow the procedures set forth in 38 C.F.R. § 3.159(c) as regards requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 3. Request all VA treatment records from the Phoenix VA Health Care System since October 2015. All records obtained should be associated with the claims file. 4. Send to the Veteran a letter requesting that he provide sufficient information and a signed and dated authorization, via a VA Form 21-4142 (Authorization and Consent to Release Information) to enable VA to obtain any additional relevant private medical records of treatment related to the issues on appeal, including any treatment of hypertension in the early 1980s. 5. Schedule the Veteran for a VA examination to assess the nature and etiology of any current lung disorder. The entire claims file, including all of the Veteran's past medical records, must be reviewed in conjunction with the examination. a) What are the Veteran's current diagnoses pertaining to the lungs? Please discuss his past diagnoses of COPD, asbestosis, asthma, and reactive airway disease, and the X-ray findings of a scar or other markings in the lower left lung. b) For every diagnosis found, is the disorder at least as likely as not (a 50 percent or higher degree of probability) related to the Veteran's active service, to include exposure to asbestos while working as a mechanic? It is noted to the examiner that the Veteran worked as a mechanic in service, and the December 2003 VA examiner has already acknowledged that the Veteran would have had "some risk" of asbestos exposure. The examiner is also asked to discuss i) the letter from private physician J.P. which states that the Veteran has a respiratory disorder caused by exposure to asbestos from 1978 to 1990, which would be post-service asbestos exposure during his civilian employment, and whether the effects of the Veteran's in-service asbestos exposure can be separated from any post-service exposure effects; and ii) the letter from A.C. stating that she remembered the Veteran having shortness of breath and bronchitis when she lived with him in 1980. c) For every diagnosis found, is it at least as likely as not caused or aggravated (worsened beyond the natural progression) by his sleep apnea or his service-connected PTSD? Please discuss the Veteran's October 2010 statement that there was a possible relationship between the Veteran's dyspnea and his sleep apnea and his anxiety. The examiner should provide reasons for these opinions. All pertinent evidence, including both lay and medical, should be considered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If he/she cannot offer an opinion without resorting to mere speculation, please indicate such in your report and explain why an opinion cannot be offered. 6. Schedule the Veteran for a VA orthopedic examination to assess the nature and etiology of any current lumbar spine condition and associated radiculopathy and the current severity of his left ankle disability. The entire claims file, including all of the Veteran's past medical records, must be reviewed in conjunction with the examination. a) What are the Veteran's current diagnoses pertaining to the lumbar spine? Please discuss his past diagnoses of lumbar spine facet arthropathy, lumbar spondylosis, degenerative disc disease, and degenerative joint disease. b) For every diagnosis found, is the disorder at least as likely as not (a 50 percent or higher degree of probability) related to the Veteran's active service? The examiner is asked to discuss i) the Veteran's assertions of injuring his back while carrying a heavy box and falling, and further injuring his back slipping in snow and in a car accident; ii) the September 2010 letter from the Veteran's colleague stating that he remembered the Veteran being in a serious car accident and complaining of back pain; and iii) the letter from the Veteran's sister stating that she remembered the Veteran having back problems after his in-service car accident. It is noted to the examiner that the Veteran's service personnel records do indicate that he was in a car accident in 1976. c) What are the Veteran's current diagnoses pertaining to radiculopathy? Please discuss the Veteran's past diagnosis of left lower extremity radiculopathy. d) Does the Veteran have lower extremity radiculopathy that is either a symptom of, or is caused or aggravated by, his lumbar spine disorder? e) Evaluate the current severity of the Veteran's service-connected left ankle disability. The examiner should indicate whether pain or weakness significantly limits functional ability during flare-ups or when the measured joints are used repeatedly over a period of time. The examiner should address whether the joints exhibit weakened movement, excess fatigability or incoordination. If feasible, these determinations should be expressed in terms of additional range of motion loss due to any weakened movement, excess fatigability, or incoordination. The examiner is asked to specifically test the range of active motion, passive motion, weight-bearing motion, nonweight-bearing motion, and, if possible, range of motion measurements of both the left and right ankles. See Correia v. McDonald, 28 Vet. App. 158 (2016). If the examiner is unable to conduct the required testing or concludes that the required testing is not possible or necessary in this case, he or she should clearly explain why that is so. The examiner should provide reasons for all opinions. All pertinent evidence, including both lay and medical, should be considered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If he/she cannot offer an opinion without resorting to mere speculation, please indicate such in your report and explain why an opinion cannot be offered. 7. Schedule the Veteran for a VA examination to assess the current severity of his service-connected folliculitis. The entire claims file, including all of the Veteran's past medical records, must be reviewed in conjunction with the examination. In accordance with the latest worksheets for rating skin disorders, the examiner is to provide a detailed review of the Veteran's pertinent medical history, current complaints, and the nature and extent of his folliculitis. The examiner is also asked to specifically discuss whether the Veteran was taking systemic therapy such as corticosteroids or other immunosuppressive drugs during the period of 2013 to the present. The examiner must state whether the Veteran was taking such drugs for less than 6 weeks, more than 6 weeks, or constantly during each of the years from 2013 to the present. If the Veteran ceased taking these drugs at any point, the examiner must clearly define the period in which the drugs were taken. The examiner should specifically address the Veteran's 2014 prescriptions for hydroxyzine and Keflex, and other past prescriptions of oral medication for treatment of his skin disorder. The examiner must set forth all examination findings with a complete explanation based on the facts of this case and any relevant medical literature for the comments and opinions expressed. 8. Schedule the Veteran for a VA examination to assess the current severity of his service-connected hearing loss. The entire claims file, including all of the Veteran's past medical records, must be reviewed in conjunction with the examination. In accordance with the latest worksheet for hearing loss, the examiner is to perform all required testing and discuss the Veteran's reports of how his hearing loss has affected his functioning. The examiner must set forth all examination findings with a complete explanation based on the facts of this case and any relevant medical literature for the comments and opinions expressed. 9. After the Veteran's respiratory examination report for lung disorders has been completed, obtain a medical opinion from a qualified physician discussing the likely etiology of the Veteran's sleep apnea. The entire claims file, including all of the Veteran's past medical records, must be reviewed. a) Is the Veteran's sleep apnea at least as likely as not (a 50 percent or higher degree of probability) related to his active service, to include either a head injury incurred during a 1976 car accident or exposure to asbestos while working as a mechanic in service? Please discuss the correspondence from the Veteran's brother stating that when the Veteran got out of the Army, he was awakened by his loud snoring and choking at night, and saw him toss and turn and be sleepy during the day. b) Is the Veteran's sleep apnea at least as likely as not caused or aggravated (worsened beyond the natural progression) by his current lung disorder? Please refer to any findings in the Veteran's VA respiratory examination, as appropriate. The examiner should provide reasons for these opinions. All pertinent evidence, including both lay and medical, should be considered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If he/she cannot offer an opinion without resorting to mere speculation, please indicate such in your report and explain why an opinion cannot be offered. 10. Obtain a medical opinion from a qualified physician discussing the likely etiology of the Veteran's renal cell carcinoma. The entire claims file, including all of the Veteran's past medical records, must be reviewed. a) Is the Veteran's renal cell carcinoma, treated with a left radical nephrectomy in 1990, at least as likely as not (a 50 percent or higher degree of probability) related to his active service, to include exposure to asbestos while working as a mechanic in service? It is noted to the examiner that the Veteran worked as a mechanic in service, and the December 2003 VA examiner has already acknowledged that the Veteran would have had "some risk" of asbestos exposure. Please discuss the letter from private physician J.P. stating that the Veteran's occupational exposure after service resulted in the development of renal cell carcinoma, and discuss whether the effects of the Veteran's in-service asbestos exposure can be separated from any post-service exposure effects. b) Do the Veteran's treatment records show any recurrence of renal cell carcinoma, to include consideration of the cyst found in the Veteran's right kidney in 2010 and 2012? If a recurrence of renal cell carcinoma is found, is it at least as likely as not related to his active service, to include exposure to asbestos? The examiner should provide reasons for these opinions. All pertinent evidence, including both lay and medical, should be considered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If he/she cannot offer an opinion without resorting to mere speculation, please indicate such in your report and explain why an opinion cannot be offered. 11. The Veteran is hereby notified that it is his responsibility to report for the examination and to cooperate in the development of the claims. The consequences for failure to report for any VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2017). 12. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ JENNIFER HWA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs