Citation Nr: 1807908 Decision Date: 02/07/18 Archive Date: 02/20/18 DOCKET NO. 16-10 643 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for atopic dermatitis. 2. Entitlement to service connection for sleep apnea. 3. Entitlement to service connection for hyperlipidemia. 4. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and anxiety disorder. 5. Entitlement to service connection for chronic sleep impairment. 6. Entitlement to service connection for lumbar spine disability. 7. Entitlement to service connection for bilateral hearing loss. 8. Entitlement to service connection for tinnitus. 9. Entitlement to service connection for bilateral hip disability. 10. Entitlement to service connection for bilateral ankle disability. 11. Entitlement to service connection for bilateral foot disability. 12. Entitlement to service connection for bilateral knee disability. 13. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus type II. 14. Entitlement to a separate, compensable rating for right lower extremity peripheral neuropathy associated with diabetes mellitus type II. 15. Entitlement to a separate, compensable rating for left lower extremity peripheral neuropathy associated with diabetes mellitus type II. 16. Entitlement to an initial rating in excess of 30 percent for nephropathy with hypertension. 17. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability (TDIU). ATTORNEY FOR THE BOARD G. E. Wilkerson, Counsel INTRODUCTION The Veteran served on active duty from May 1968 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. The Board notes that the RO rated the Veteran's service-connected diabetes mellitus type II and peripheral neuropathy of the bilateral lower extremities as one disability, with peripheral neuropathy considered a noncompensable manifestation of diabetes mellitus. However, the Board has considered whether the Veteran's peripheral neuropathy of the bilateral lower extremities warrant separate compensable ratings, as noted on the title page. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of entitlement to service connection for atopic dermatitis, bilateral hip, ankle, and foot disabilities and lumbar spine disability, as well as the claim for TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Sleep apnea did not manifest in service and is not related to service. 2. Hyperlipidemia is a laboratory finding and is not a disability. 3. An acquired psychiatric disorder, to include PTSD and anxiety disorder, is not shown by the record. 4. A disability manifested by chronic sleep impairment is not shown by the record. 5. The Veteran does not have a hearing loss disability of either ear as defined in VA law and regulations. 6. Tinnitus did not manifest in service or within one year of separation from service and is not otherwise related to service. 7. A chronic bilateral knee disability did not manifest in service or within one year of separation from service and is not otherwise related to service. 8. The Veteran's diabetes mellitus type II has required oral hypoglycemic agents and restricted diet, but not insulin, restricted diet, and regulation activities; episodes of ketoacidosis or hypoglycemic reaction requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider have not been shown. 9. The Veteran's peripheral neuropathy of the right and left lower extremities, secondary to diabetes mellitus, is manifested by no more than mild incomplete paralysis of the sciatic nerves of each leg. 10. The Veteran's nephropathy with hypertension is manifested by high blood pressure, proteinuria, and elevated urinary microalbumin; constant albuminuria with some edema, definite decrease in kidney function, or diastolic pressure predominantly 120 or more has not been shown. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 2. The criteria for service connection for a disability manifested by hyperlipidemia have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 3. The criteria for service connection for an acquired psychiatric disorder, to include PTSD and anxiety disorder, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 4. The criteria for service connection for a disability manifested by chronic sleep impairment have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 5. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 6. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 7. The criteria for service connection for bilateral knee disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 8. The criteria for a rating in excess of 20 percent for diabetes mellitus type II have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2017). 9. The criteria for a separate 10 percent rating for right lower extremity peripheral neuropathy associated with diabetes mellitus type II have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). 10. The criteria for a separate 10 percent rating for left lower extremity peripheral neuropathy associated with diabetes mellitus type II have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). 11. The criteria for a rating in excess of 30 percent for nephropathy with hypertension have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.115b, Diagnostic Code 7541 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The Veteran has not raised any issues with the duty to notify. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). The Board acknowledges that the Veteran has not been afforded a VA examination with respect to his service-connection claims for sleep apnea, chronic sleep impairment or hyperlipidemia for opinion as to whether these disabilities are related to service. However, for the reasons explained in greater detail below, no such examination is required because the credible evidence does not indicate a current claimed disability, or that a claimed disability and/or symptoms thereof, may be associated with the Veteran's service. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Under McLendon, in disability compensation claims, VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. Id. A VA examination under the standards of McLendon is not warranted for these claimed disabilities. The competent and credible evidence of record does not suggest current disability, in the case of hyperlipidemia or chronic sleep impairment, or persistent or recurrent symptoms since service, or a relationship to service, in the case of sleep apnea. Thus, the Board finds that the duty to assist is not invoked, even under McLendon, as here the evidence fails the McLendon analysis for these claims. A mere conclusory generalized statement that a service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (discussing the circumstances when a VA examination and opinion are required). For these reasons, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The claims on appeal herein decided are thus ready to be considered on the merits. I. 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. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To show a chronic disease in service, a combination of manifestations sufficient to identify the disease entity is required, as is sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). The Court has established that 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C. § 1101. With respect to the current appeal, that list includes an organic diseases of the nervous system (including tinnitus), psychoses, arthritis, and cardiovascular-renal disease. See 38 C.F.R. § 3.309(a). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including organic diseases of the nervous system, psychoses, arthritis, and cardiovascular-renal disease are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). However, in order for the presumption to apply, the evidence must indicate that the disability became manifest to a compensable (10 percent) degree within one year of separation from service. See 38 C.F.R. § 3.307. Veterans who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence of non-exposure. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to an herbicide agent during active service, certain enumerated diseases, including diabetes mellitus and ischemic heart disease, shall be presumptively service-connected even where there is no record of such disease during service, provided that the disease is manifested to a compensable degree as set forth in 38 C.F.R. § 3.307, and the rebuttable presumption provisions of 38 C.F.R. § 3.307 are met. See 38 C.F.R. § 3.309(e); see also 38 C.F.R. § 3.307(a)(6)(ii) (providing that with the exception of chloracne or other acneform disease, porphyria cutanea tarda, and early onset peripheral neuropathy, the diseases listed in 38 C.F.R. § 3.309(e) must be manifest to a degree of 10 percent or more at any time after service). The Veteran served in Vietnam from 1968 to 1969 and therefore is presumed to have been exposed to Agent Orange. However, to the extent that the Veteran alleges disabilities due to Agent Orange exposure none of the claimed disabilities are among the enumerated diseases in 38 C.F.R. § 3.309(e) that a presumed due to herbicide exposure. However, the regulations governing presumptive service connection for herbicide exposure do not preclude a veteran from establishing service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039 (1994). The Board will adjudicate the claims on a theory of direct entitlement to service connection. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. A. Sleep Apnea The Veteran's service treatment records include no complaint, finding, or diagnosis with respect to sleep apnea. No sleep related complaints were noted on December 1969 report of medical history at discharge, and no related abnormalities were found on discharge examination at that time. Following service, private and VA treatment records reflect the Veteran underwent a sleep study in 2014. Findings were consistent with mild obstructive sleep apnea. He used a CPAP machine for treatment. In a January 2014 statement, Dr. Q. wrote that the Veteran had chronic sleep impairment. The Veteran has not submitted any lay statement as to why he believes that the claimed disability is related to service. This first evidence of the claimed sleep apnea is in 2014, more than 50 years after discharge from service. The Board finds that this long passage of time between service and seeking treatment weighs against the claim, particularly in the absence of even lay evidence of symptomatology in closer proximity to service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and any medical complaints or documentation of a claimed disability is a factor that may weigh against a claim for service connection);38 C.F.R. § 3.303(b). Moreover, none of the probative evidence supports a finding of a relationship between the Veteran's sleep apnea and service. Accordingly, the claim for service connection for sleep apnea must be denied. 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. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). B. Hyperlipidemia The Veteran also seeks service connection for hyperlipidemia. A post-service, January 2014 report from Dr. Q. reflects assessment of hyperlipidemia and hypertension. He opined that the Veteran's cardiovascular disorder was more probable than not secondary to his performance and Agent Orange contact during service. However, a specific cardiovascular disorder was not identified, other than hypertension. However, hyperlipidemia is a laboratory finding and is not a disability in and of itself for which VA compensation benefits are payable. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (Diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule.). The term "disability" as used for VA purposes refers to impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In this case, a disability associated with elevated lipids that manifest in service or is related to service has not been shown. The Board notes that the Veteran is already service-connected for nephropathy with hypertension. As there is no disability, the Board does not reach the issue of whether the claimed disability is related to service, to include Agent Orange exposure therein. In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366 (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Fagan, 573 F.3d at 1287 (Fed. Cir. 2009). C. Psychiatric Disorder The Veteran's service treatment records reflect no complaint, finding, or diagnosis with respect to the claimed psychiatric disorder. The Veteran denied frequent trouble sleeping, frequent or terrifying nightmares, depression or worry, or nervous trouble of any sort on report of medical history at discharge. No psychiatric abnormalities were found on December 1969 discharge examination. Following service, in a January 2014 statement, Dr. Q. noted that the Veteran complained of nervousness, anxiety, irritability, impaired impulse control, isolation, and difficulty in establishing effective work and social relationships. He also had insomnia with nightmares and flashbacks of his traumatic experiences during service. Diagnosis of generalized anxiety disorder, chronic sleep impairment, and PTSD were indicated. Dr. Q. indicated that the Veteran's psychiatric disorders were more likely than not secondary to his performance and Agent Orange contact during service. On VA examination in November 2014, the Veteran reported that he served in Vietnam but was not involved in combat. After service, he worked for 42 years with the government of Puerto Rico, and then subsequently worked for 5 years at a friend's business. He retired in 2007. He did not have a history of psychiatric complaints, findings, or treatment at the VA medical center or any private institution. There was no history of hospitalization or emotional crisis. He was not following any psychotherapy or pharamacotherapy. The examiner noted that while the Veteran met the DSM-V stressor criteria for PTSD, he did not meet the symptoms criteria, including persistent re-experiencing of the traumatic events, avoidance of stimulus, or hyperarousal. In addition, the trauma did not cause impairment in social, occupational, or other areas of functioning. While there was mild occasional insomnia due to sleep apnea, this was a single symptom and did not constitute a full mental condition. In sum, the examiner determined that the Veteran did not have a diagnosis of PTSD that conformed to the DSM-V criteria. He also did not have another mental disorder that conformed to DSM-V criteria. He noted that clinical history, psychosocial course, and mental status examination performed on examination were negative for a mental condition. As to current disability, the record contains competing opinions as to whether the Veteran meets the criteria for psychiatric diagnosis, to include PTSD. While Dr. Q. noted diagnoses of PTSD and generalized anxiety disorder, the VA examiner determined that no diagnosis was warranted. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Unlike the VA examiner, Dr. Q. noted his diagnoses without any indication of review of the record, performance of mental status examination and evaluation, or consideration of the DSM-V criteria. There was no rationale provided for the conclusions reached. As such, the Board finds the diagnoses of little probative value and clearly outweighed by the VA examination of record, which concluded that after interview of the Veteran, review of the record, consideration of the diagnostic criteria, interview, testing, and mental status examination, that a diagnosis of PTSD or other psychiatric disorder was not warranted. Accordingly, the most probative evidence of record is against the finding of a current psychiatric disorder. The Board has also considered the lay statements of the Veteran to the effect that he has PTSD and anxiety disorder. Lay evidence is competent when reporting a contemporaneous diagnosis. Jandreau v. Nicholson, 492 F3d. 1372 (2007). Given the notations of diagnosis of PTSD and anxiety noted above, the Veteran appears to reporting a contemporaneous diagnosis and is thus competent in this regard. However, also as noted above, Dr. Q. did not give any rationale for the conclusions reached or specifically discuss whether a diagnosis under the DSM-V was appropriate. Accordingly, the probative value of the Veteran's general assertions in this regard is outweighed by the probative value of the specific, reasoned opinion of the VA examiner, who determined that the Veteran did not meet the criteria for diagnosis of PTSD or other psychiatric disorder. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110. See also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Therefore, where, as here, competent evidence indicates that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection for the disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, without persuasive evidence of current diagnosis of PTSD or other acquired psychiatric disorder, there is no basis upon which to award service connection, and discussion of the remaining criteria for service connection, to include that for PTSD under 38 C.F.R. § 3.304(f), is unnecessary. In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366 (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Fagan, 573 F.3d at 1287 (Fed. Cir. 2009). D. Chronic Sleep Impairment The Veteran also contends that he is entitled to service connection for disability manifested by chronic sleep impairment. As noted above, in a January 2014 statement, Dr. Q. noted that the Veteran complained of insomnia with nightmares. Diagnosis of generalized anxiety disorder, chronic sleep impairment, and PTSD were indicated. On VA examination in November 2014, mild occasional insomnia due to sleep apnea was indicated. In addition, the Veteran was diagnosed with sleep apnea in 2014. To the extent that the Veteran's sleep problems have been attributed to sleep apnea or to an acquired psychiatric disorder, these disabilities are addressed in separate claims addressed above. Otherwise, there is no indication of a current disability manifested by sleep impairment. Again, the Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110. See also McClain, 21 Vet. App. 319, 321 (2007). Accordingly, where, as here, competent evidence indicates that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection for the disability. See Gilpin, 155 F.3d at 1353; Brammer, 3 Vet. App. at 225. Thus, without persuasive evidence of current diagnosis of a separate disability manifested by sleep impairment, there is no basis upon which to award service connection, and discussion of the remaining criteria for service connection is unnecessary. In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366 (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich, 104 F.3d at 1332. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Fagan, 573 F.3d at 1287 (Fed. Cir. 2009). E. Hearing Loss and Tinnitus The Veteran also seeks service connection for hearing loss and tinnitus due to in-service noise exposure. In addition to the above-noted legal criteria regarding service connection, there are also specific requirements regarding what constitutes a hearing loss disability under VA law. The threshold for normal hearing is from 0 to 20 decibels. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). 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, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz 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. The Veteran's service treatment records include no complaint, finding, or diagnosis with respect to hearing loss or tinnitus. No audiometric findings were included on discharge examination in December 1969. The Veteran denied hearing loss or ear, nose or throat trouble on report of medical history at discharge. In a January 2014 statement, private physician Dr. Q. reflects that "since military service in Vietnam" the Veteran complained of earache, dizziness, tinnitus and bilateral hearing loss due to noise exposure in service. Diagnoses of bilateral deafness and tinnitus were indicated. On VA examination in November 2014, the Veteran reported a buzzing sounds in both ears for about 2 years. He could not specify the date or circumstances of onset. On the audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 15 25 25 LEFT 15 15 15 20 20 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 100 percent in the left ear. The examiner diagnosed normal hearing. The examiner opined that the Veteran's claimed tinnitus is not related to noise exposure from service. In so finding, the examiner noted that the Veteran reported onset 2 years prior to examination and could not specify the circumstances of onset, there was no evidence of tinnitus in service or shortly thereafter, and there was no record of audiological workup until the examination. With respect to the claimed bilateral hearing loss, the above-cited testing results do not establish a current bilateral hearing loss disability as defined by 38 C.F.R. § 3.385, as the auditory thresholds were not 40 decibels or greater at any of the frequencies, the auditory thresholds at the minimum three of the frequencies were not 26 decibels or greater, and the Maryland CNC speech recognition scores noted on VA examination were not less than 94 percent. See 38 C.F.R. § 3.38. Moreover, the Veteran has not presented or identified existing audiometric testing results that meet the requirements of that regulation for hearing loss. Hence, the Veteran does not have a bilateral hearing loss disability for VA purposes. The test results are controlling and clearly more probative than his lay evidence. The Board acknowledges Dr. Q.'s assessment of hearing loss and "bilateral deafness." The Board also notes that the Veteran is competent to report that which he has personally experienced, such as noise exposure and hearing problems. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Furthermore, the Board finds the Veteran's statements concerning his noise exposure and decreased hearing are credible. But, there is a difference between hearing loss and hearing loss disability. VA regulations establish when such hearing loss reaches the level of disability for VA purposes. Palczewski v. Nicholson, 21 Vet. App. 174, 179-80 (2007). With respect to the extent of his decreased hearing acuity, the Board places greater probative weight to the audiometric and word list testing results-performed by a trained audiologist-which provides a more objective measure of the Veteran's hearing acuity. Again, in the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366 (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich, 104 F.3d at 1332. In regard to the claimed tinnitus disability, the Board notes that the record reflects post-service diagnosis of tinnitus. Here, the Veteran reported on examination remote onset of tinnitus, rather than an in-service onset of tinnitus. Again, the Veteran is certainly competent to report as to the symptoms he experiences, such as hearing difficulty, and their history. However, the Veteran's statements of record do not establish a consistent report of symptomatology to establish continuity since service. Rather, the Veteran has merely indicated that he has hearing loss and tinnitus due to noise exposure during service. He has not expressed onset of tinnitus in service. The Board notes Dr. Q. notes tinnitus "since service," but a specific date or circumstance of onset was not identified. The Board notes that there are competing opinions of record with regard to whether the Veteran's tinnitus is due to in-service noise exposure, with Dr. Q. linking the disability to service and the VA examiner finding such a relationship less likely than not. As noted above, it is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes, 5 Vet. App. at 69-70. The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri, 4 Vet. App. at 470-71. When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens, 7 Vet. App. at 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert, 5 Vet. App. at 30; see also Colvin, 1 Vet. App. at 171. In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens, 11 Vet. App. at 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean, 13 Vet. App. at 448-49. A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez, 22 Vet. App. at 304. In this case, the Board finds the VA examiner's opinion more probative. In so finding, the Board observes that, unlike the VA examiner, Dr. Q. did not note review of the record, including service treatment records, and did not include any rationale for the conclusions reached. In contrast, the VA examiner based her opinion upon review of the record and interview and examination of the Veteran, with fully supported rationale. As such, the Board finds Dr. Q.'s opinion clearly outweighed by the VA examination of record and of little probative value. The record establishes that an organic disease of the nervous system (tinnitus) was not "noted" during service or within one year of separation. Furthermore, the objective evidence establishes that he did not have characteristic manifestations of the disease during service. 38 C.F.R. § 3.303(b). Rather, the in-service findings were normal. To the extent that any of the Veteran's statements imply his belief that tinnitus is related to service, the Board notes that the Veteran is competent to testify to his observations, and the Board concedes his in-service noise exposure. However, on the question as to whether current tinnitus is related to in-service noise exposure, the specific, reasoned opinions of the VA audiologist and physician who performed the 2014 VA examination is of greater probative weight than the more general assertions of the Veteran, even assuming the Veteran's competence to opine on this medical question. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011). Based on the foregoing, the preponderance of the evidence is against the claims for service connection for bilateral hearing loss and tinnitus. The benefit-of-the-doubt doctrine is therefore not for application, and the claims must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan, 573 at 1282, 1287. F. Bilateral Knees The Veteran likewise seeks service connection for bilateral knee disability. The Veteran's service treatment records reflect that in June 1968, he complained of right knee pain. No swelling or deformity was present. No further complaints or treatment of the knee was indicated. On report of medical history at discharge in December 1969, the Veteran denied bone, joint or other deformity and trick or locked knee. On discharge examination, no abnormalities with respect to the right or left lower extremity were found. In a January 2014 statement, Dr. Q. wrote that the Veteran had numbness, tingling, and cramps in the paravertebral muscles radiating to both hips, knees, ankles, and feet. He needed assistance with squatting, sitting, or standing. Diagnosis of osteoarthritis of both knees was indicated. Dr. Q. concluded that the Veteran's musculoskeletal disorders were more probable than not secondary to his performance and Agent Orange exposure during service. On VA examination in November 2014, the Veteran reported left knee pain and locking since approximately 2 years prior to examination. He denied any twisting injury or trauma. He described being functionally impaired in ambulation due to pain and numbness radiating down from his back, but not due to knee pain. After physical examination, the examiner diagnosed bilateral patellofemoral pain syndrome and left knee medial meniscus tear. The examiner concluded that the claimed knee condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In so finding, the examiner noted that service treatment records did not show a left or right knee condition or recurrent knee injury or pain. The separation examination did not report any knee complaints. There were no medical notes showing knee pain or condition for more than 40 years after separation found. There was no link for the present left knee medial meniscus tear or the bilateral patellofemoral pain syndrome. In sum, there is post-service diagnosis of right and left knee disorders, including osteoarthritis, patellofemoral syndrome and meniscus tear. With respect to nexus, there are again competing opinions of records, that of Dr. Q. and the VA examiner. In this case, the Board finds the VA examiner's opinion more probative. In so finding, the Board observes that, unlike the VA examiner, Dr. Q. did not note review of the record, including service treatment records, and did not include any rationale for the conclusions reached. In contrast, the VA examiner based his opinion upon review of the record and interview and examination of the Veteran, with fully supported rationale. As such, the Board finds Dr. Q.'s opinion clearly outweighed by the VA examination of record and of little probative value. Accordingly, the most probative opinion weighs against the Veteran's claim. The record establishes that arthritis was not "noted" during service or within one year of separation. Furthermore, the objective evidence establishes that he did not have characteristic manifestations of the disease during service. 38 C.F.R. § 3.303(b). While there is one complaint of right knee pain in service, no further findings with respect to either knee were noted in service, and the lower extremities were normal at discharge from service. To the extent that the Veteran contends that his bilateral knee disability is related to service, the Board acknowledges that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, 581 F.3d at 1316. In any event, the probative value of the Veteran's general assertions in this regard is outweighed by the probative evidence of record outlined above, including the specific, reasoned opinions from the VA examiner. Based on the foregoing, the preponderance of the evidence is against the claim for service connection for bilateral knee disability. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan, 573 at 1282, 1287. II. Increased Rating Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. 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). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). A. Diabetes Mellitus and Peripheral Neuropathy The Veteran's diabetes mellitus is rated as 20 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code 7913. Diagnostic Code 7913 provides for a 20 percent rating for diabetes that requires insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet. A 40 percent rating is warranted when diabetes requires insulin, restricted diet, and regulation of activities. A 60 percent rating is assigned where insulin, restricted diet, and regulation of activities are required, with episodes of ketoacidosis or hypoglycemia reactions required one to two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. "Regulation of activities" is defined by Diagnostic Code 7913 as the "avoidance of strenuous occupational and recreational activities." Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007) (citing 61 Fed.Reg. 20,440 (May 7, 1996). Complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are deemed part of the diabetic process. In this case, the Veteran's peripheral neuropathy of the bilateral lower extremities is treated as a noncompensable complication and is included with the rating for diabetes mellitus. The Veteran is seeking a higher rating for the disability, to include separate ratings for peripheral neuropathy. VA treatment records dated in 2013 and 2014 reflect diagnosis of diabetes mellitus with treatment of the oral agent Metformin and a diabetic diet. No gross motor or sensory deficits were indicated. A January 2014 statement from Dr. Q. reflects that the Veteran had polyuria, polydipsia, polyphagia, dizziness, and episodes of numbness, sensorial loss, cramps, and severe pain in both lower limbs. He was in active treatment with poor blood glucose control. Diagnoses of diabetes mellitus and diabetic neuropathy of both lower limbs was indicated. On VA examination in November 2014, the Veteran reported that he had been using one oral hypoglycemic medication and his glycemic control had been good. His only diabetes-related complaint was numbness and tingling in the feet. The examiner noted that the Veteran's treatment for diabetes mellitus included management by restricted diet and prescribed oral hypoglycemic agents. The Veteran did not require regulation of activities as part of his management. He went to his diabetic care provider for episodes of ketoacidosis or hypoglycemia less than 2 times per month. He had not required hospitalization for any episodes in the past 12 months. He did not have any unintentional weight loss or loss of strength attributable to diabetes mellitus. Complications included peripheral neuropathy and diabetic nephropathy. On VA peripheral nerves examination in November 2014, the Veteran reported numbness and tingling in the feet. He denied symptoms in the hands. Symptoms included moderate paresthesias or dysestheias in the bilateral lower extremities and moderate numbness of the bilateral lower extremities. On neurological examination, strength was full in the bilateral lower extremities. Deep tendon reflexes were normal in the right and left knee, but decreased in the right and left ankle. Sensation was decreased to light touch in the feet and toes, but normal in the knees, thighs, ankles, and lower legs. Vibration sensation was also decreased in the bilateral lower extremities. The Veteran did not have muscle atrophy. The examiner noted that the Veteran did have diabetic peripheral neuropathy, but the bilateral sciatic and femoral nerves were normal. The examiner indicated that the Veteran's peripheral neuropathy was sensory-type. In this case, the record reflects that the Veteran's diabetes mellitus is treated with oral hypoglycemic agents and restricted diet, consistent with a 20 percent rating. Use of insulin, restricted diet, and regulation of activities are not demonstrated, and there is no indication of frequent treatment or hospitalization or treatment more than twice a month for episodes of ketoacidosis or hypoglycemia reactions. Accordingly, a rating in excess of 20 percent is not warranted. As for the Veteran's related diabetic peripheral neuropathy of the lower extremities, the Board finds that separate, 10 percent ratings for each lower extremity are warranted. Under Diagnostic Code 8520, for paralysis of the sciatic nerve, mild incomplete paralysis of the sciatic nerve warrants a 10 percent rating. A 20 percent rating requires moderate incomplete paralysis of the sciatic nerve. A 40 percent rating requires moderately severe incomplete paralysis of the sciatic nerve. A 60 percent rating requires severe incomplete paralysis with marked muscular atrophy. An 80 percent rating requires complete paralysis. When there is complete paralysis, the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. When the involvement is wholly sensory, the rating should be of the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The findings of the November 2014 VA examiner reflect decreased sensation and reflexes of the feet. Despite the examiner's finding of no nerve impairment, such findings are consistent with a 10 percent rating for mild incomplete paralysis. However, the Board also finds that a rating in excess of 10 percent is not warranted for either extremity. Here, the VA examiner indicated that the disabilities are wholly sensory. While sensation is decreased in the feet, it is not absent and sensation is otherwise intact in the legs. Motor examination was normal, and reflexes were only decreased in the ankles. Although Dr. Q. appears to have suggested more severe findings in the legs, there are no accompanying neurological studies. Accordingly, the Board finds that the criteria for moderate incomplete paralysis have not been more nearly approximated. Moreover, the Board has considered whether there are additional, separately ratable complications associated with the Veteran's diabetes mellitus, but has found none other than that for which service-connection is already in effect. Accordingly, the Board finds that while separate 10 percent ratings for peripheral neuropathy of each lower extremity is warranted, a rating in excess of 20 percent for diabetes mellitus must be denied. B. Nephropathy with Hypertension The Veteran's nephropathy with hypertension, secondary to his diabetes mellitus type II, is rated as 30 percent disabling pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7541. This diagnostic code provides that renal involvement in diabetes mellitus is to be rated as renal dysfunction. With respect to renal dysfunction, a 0 percent rating for albumin and casts with a history of acute nephritis; or, hypertension noncompensable under diagnostic code 7101. A 30 percent rating is warranted for albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101. A 60 percent rating is warranted for constant albuminuria with some edema, or definite decreased in kidney function, or hypertension at least 40 percent disabling under diagnostic code 7101. An 80 percent rating is assigned for persistent edema and albuminuria with BUN 40 to 80mg%, or creatinine 4 to 8mg%, or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Finally, a 100 percent rating is warranted for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria, or BUN more than 80mg%, or creatinine more than 8mg%, or markedly decreased function of the kidney or other organ systems, especially cardiovascular. 38 C.F.R. § 4.115b. VA treatment records dated from 2013 to 2014 include blood pressure readings of 158/74, 138/80, 138/70, 148/76. A January 2014 statement from Dr. Q. reflects that the Veteran had polyuria, polydipsia, polyphagia, and dizziness. He was in active treatment with poor blood glucose control. Diagnosis of diabetes mellitus was indicated. On VA examination in November 2014, the examiner noted that the Veteran had been found with elevated urinary microalbumin values and therefore, diagnosis of diabetic nephropathy was warranted. He took Lisinopril daily. There was evidence of renal dysfunction, but the Veteran did not require regular dialysis. He had constant proteinuria. He did not have, nor had ever had, a kidney, urethral or bladder calculi. He did not have a history of recurrent or symptomatic urinary tract or kidney infections. Laboratory studies revealed that BUN was normal as was urinalysis. The examiner diagnosed diabetic nephropathy and indicated that the disability did not impact the Veteran's ability to work. The Veteran was also afforded examination for hypertension. He took Lisinopril daily for control of his hypertension. He did not have a history of diastolic blood pressure elevation to predominantly 100 or more. On examination, readings were 171/88, 170/90, and 171/88. The examiner indicated that the Veteran's hypertension did not impact his ability to work. In sum, the record reflects that the Veteran's nephropathy is productive of hypertension, proteinuria, and elevated urinary microalbumin. However, constant albuminuria with some edema, or definite decrease in kidney function is not demonstrated. In addition, while hypertension is documented, there is no indication of diastolic pressure predominantly 120 or more. See 38 C.F.R. § 4.104, Diagnostic Code 7101. In addition, BUN level was normal and there is no indication in the record of generalized poor health characterized by symptoms such as lethargy, anorexia, or limitation of exertion. Accordingly, the Board finds that a rating in excess of 20 percent for nephropathy is not warranted. The Board has considered the Veteran's contention that his hypertension should be rated separately; however, the diagnostic criteria are quite clear and hypertension is rated as a manifestation of renal dysfunction. C. Both Claims The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (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). Accordingly, the Board finds that ratings in excess of 30 and 20 percent, respectively, for the service connected nephropathy with hypertension and diabetes mellitus type II are not warranted; however, separate 10 percent ratings each for peripheral neuropathy of the bilateral lower extremities are warranted. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan, 573 at 1282, 1287. ORDER Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for hyperlipidemia is denied. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and anxiety disorder, is denied. Entitlement to service connection for chronic sleep impairment is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for bilateral knee disability is denied. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus type II is denied. Entitlement to a separate, 10 percent rating for peripheral neuropathy of the right lower extremity is granted, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a separate, 10 percent rating for peripheral neuropathy of the left lower extremity is granted, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to an initial rating in excess of 30 percent for nephropathy with hypertension is denied. REMAND Upon review of the claims file, the Board believes that additional development on the remaining claims is warranted. VA will provide a medical examination or obtain a medical opinion if the record, including lay or medical evidence, contains competent evidence of a disability that may be associated with an event, injury, or disease that occurred in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C. § 5103A(d); McLendon, 20 Vet. App. at 79 (2006). The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon, 20 Vet. App. at 83. Dermatitis A January 2014 report from Dr. Q. reflects that the Veteran presented with erythematous eruptions, pruritus, and itching, scaling, and thickened skin. A diagnosis of atopic dermatitis was indicated. Dr. Q. wrote that the Veteran's dermatological disorder was more probable than not secondary to his performance and Agent Orange contact during military service. The Board notes that the Veteran's service treatment records include no complaints, findings, or diagnoses with respect to the claimed skin disorder. Moreover, dermatitis is not a disability that is presumed to be due to Agent Orange exposure. Dr. Q. provided no rationale or discussion in support of the conclusion reached. Given the foregoing, the Board finds that medical examination with opinions based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly stated rationale, would be helpful in resolving the claim for service connection. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Lumbar Spine, Bilateral Hip, Bilateral Ankle, and Bilateral Feet Disabilities A January 2014 report from private physician Dr. Q. reflects that the Veteran had low back pain with numbness, tingling , and cramps in the paravertebral muscles radiating to both hips, knees, ankles, and feet. He needed assistance to squat, sit or stand. Diagnoses of chronic myositis of the lumbar spine, and osteoarthritis of both hips, ankles, and feet were indicated. Dr. Q. related the Veteran's musculoskeletal disabilities to his performance during military service. An October 2014 VA treatment includes lumbosacral spine spondyloarthritis in the problems list. The Board notes that the Veteran's service treatment records include no complaints, findings, or diagnoses with respect to the claims disabilities of the lumbar spine, hips, ankles, and feet. Dr. Q. provided no rationale or discussion in support of the conclusion reached. Given the foregoing, the Board finds that medical examination with opinions based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly stated rationale, would be helpful in resolving the claims for service connection. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. TDIU In regard to the claim for a TDIU, as any decision with respect to the claims for service connection may affect the Veteran's claim for a TDIU, the claim for a TDIU is inextricably intertwined with the claims for increased rating and service connection. As the claims should be considered together, it follows that, any Board action on the TDIU claim, at this juncture, would be premature. Hence, a remand of this matter is warranted, as well. Accordingly, the case is REMANDED for the following action: 1. Assist the Veteran in associating with the claims folder updated treatment records, including updated VA treatment records. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed skin disability. Any indicated tests should be accomplished. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history. The examiner should identify all skin disorders. Then, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any skin disorder manifest in service, or is otherwise medically related to service, to include Agent Orange exposure therein. The examiner is asked to consider and address the January 2014 opinion of Dr. Q. in rendering his/her opinion. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. 3. Schedule the Veteran for a VA examination(s) to determine the nature and etiology of the claimed lumbar spine, bilateral hip, bilateral ankle, and bilateral foot disabilities. Any indicated tests should be accomplished. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history. The examiner should identify all lumbar spine, right and left hip, right and left ankle, and right and left foot disorders. Then, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any lumbar spine, bilateral hip, bilateral ankle, or bilateral foot disorder manifest in service or within one year of discharge, or is otherwise medically related to service. The examiner is asked to consider and address the January 2014 opinion of Dr. Q. in rendering his/her opinion. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. 4. The AOJ should undertake any additional development it deems warranted. 5. Then, the AOJ should readjudicate the Veteran's claims. If the benefits sought on appeal are not granted, the Veteran and his representative should be provided a Supplemental Statement of the Case and afforded the requisite opportunity to respond before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter or 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). ____________________________________________ A. S. CARACCIOLO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs