Citation Nr: 18134685 Decision Date: 09/13/18 Archive Date: 09/13/18 DOCKET NO. 10-38 475 DATE: September 13, 2018 ORDER A rating of 30 percent for service-connected cervical spine disorder for the period from April 27, 2009, to December 31, 2014, is granted. A rating of 20 percent for service-connected lumbar spine disorder for the period from April 27, 2009, to December 31, 2014, is granted. A rating in excess of 10 percent for service-connected tinnitus is denied. Service connection for compensation purposes for a dental disability manifested by teeth and gum pain is denied. REMANDED Entitlement to service connection for a bilateral knee disorder is remanded. Entitlement to service connection for hearing loss is remanded. Entitlement to service connection for an upper respiratory disorder to include sinusitis and/or allergic rhinitis is remanded. Entitlement to service connection for varicose veins is remanded. Entitlement to service connection for a skin rash of the bilateral hands is remanded. Entitlement to service connection for foot fungus, to include tinea pedis, is remanded. Entitlement to service connection for recurrent headaches is remanded. Entitlement to service connection for disability manifested by tingling and numbness of the upper extremities is remanded. FINDINGS OF FACT 1. For the period from April 27, 2009, to December 31, 2014, the competent and credible evidence of record reflects the service-connected cervical spine disorder more nearly approximated than not the criteria of forward flexion limited to 15 degrees or less. 2. For the period from April 27, 2009, to December 31, 2014, the competent and credible evidence of record reflects the service-connected lumbar spine disorder more nearly approximated than not the criteria of forward flexion limited to 60 degrees or less. 3. The Veteran’s tinnitus is assigned the maximum rating available under Diagnostic Code 6260. 4. The record does not reflect the Veteran had a dental disability for which compensation may be paid. CONCLUSIONS OF LAW 1. The criteria for a rating of 30 percent for service-connected cervical spine disorder for the period from April 27, 2009, to December 31, 2014, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5235-5243. 2. The criteria for a rating of 20 percent for service-connected lumbar spine disorder for the period from April 27, 2009, to December 31, 2014, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5235-5243. 3. The criteria for a rating in excess of 10 percent for service-connected tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.87, Diagnostic Code 6260 (2016); Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). 4. The criteria for a grant of service connection for compensation purposes for a dental disability manifested by tooth and gum pain have not been met. 38 U.S.C. §§ 1712, 5107; 38 C.F.R. §§ 3.381, 4.150, 17.161. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The record reflects the Veteran served on active duty in the United States Army from January 2004 to May 20014, and from October 2004 to January 2006, which included service in the Southwest Asia Theater of Operations form December 2004 to December 2005. Further, the record reflects he had additional service in the National Guard/Reserves. This matter is before the Board of Veterans’ Appeals (Board) originally on appeal from a June 2009 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the hearing loss claim was the subject of a prior denial, and the June 2009 rating decision initially determined that new and material evidence had not been received to reopen this claim. However, the Board finds that new and material evidence has been received to reopen this claim in accord with 38 C.F.R. § 3.156(a). Therefore, in the adjudication that follows the Board will address the merits of the underlying service connection claim. The Board also notes that the cervical and lumbar spine claims originated from the Veteran’s disagreement with the June 2009 rating decision continuation of 10 percent evaluations for these disabilities. However, ratings of 30 and 20 percent were subsequently assigned for these disabilities, effective December 31, 2014; and the Veteran has indicated he is satisfied with those ratings. As such, the issues on appeal are whether ratings in excess of 10 percent are warranted prior to December 31, 2014. In addition, the Board notes that a claim for service connection for a dental condition is also considered a claim for VA outpatient dental treatment. Mays v. Brown, 5 Vet. App. 302, 306 (1993). In dental claims, the RO adjudicates the claim of service connection and the VA Medical Center adjudicates the claim for outpatient treatment. See 38 C.F.R. § 3.381(a); 77 Fed. Reg. 4469 (Jan. 30, 2012). As this matter stems from an adverse RO determination, the appeal is limited to the issue of entitlement to service connection for a dental disability for compensation purposes. The issue of entitlement to service connection for VA dental treatment purposes is REFERRED to the appropriate agency of original jurisdiction (AOJ) for appropriate action. The Board further notes that the Veteran also initiated an appeal with the June 2009 rating decision’s denial of service connection for an acquired psychiatric disorder. However, service connection was subsequently established for posttraumatic stress disorder (PTSD) by a July 2010 rating decision. A review of the record does not reflect the Veteran perfected an appeal as to the initial rating(s) and effective date(s) assigned for this disability. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (Where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). Similarly, the record reflects the Veteran had an appeal on the issue of entitlement to a total rating based upon individual unemployability (TDIU), but that benefit was granted by an April 2018 rating decision and it does not appear he has disagreed with the effective date thereof. Accordingly, the Board finds that these issues are not presently before it for appellate consideration. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Increased Rating Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations applies, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The degree of impairment resulting from a disability is a factual determination and generally the Board’s primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the rule from Francisco does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability. Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found – a practice known as “staged” ratings. More recently, the Court held that “staged” ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. A rating of 30 percent for service-connected cervical spine disorder for the period from April 27, 2009, to December 31, 2014, 2. A rating of 20 percent for service-connected lumbar spine disorder for the period from April 27, 2009, to December 31, 2014, In this case, the Board notes that the Veteran initiated his current increased rating claims for his service-connected cervical and lumbar spine disorders by documentation received by VA on April 27, 2009. A review of the record does not reflect there was an unadjudicated increased rating claim prior to that date. Therefore, the focus of this case is the period from April 27, 2009, to December 31, 2014. Normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Further, the normal ranges of motion for each component of spinal motion are the maximum that can be used for calculation of the combined range of motion. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2), as added by 68 Fed. Reg. 51,454 (Aug. 27, 2003). The General Rating Formula for Diseases and Injuries of the Spine provides that with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. An evaluation of 20 percent is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Forward flexion of the cervical spine to 15 degrees or less; or, favorable ankylosis of the entire cervical spine warrants a 30 percent evaluation. An evaluation of 40 percent is warranted for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. An evaluation of 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine. An evaluation of 100 percent requires unfavorable ankylosis of the entire spine. Initially, the Board notes that both the service-connected cervical and lumbar spine disorders have been manifested by complaints of pain throughout the pendency of this case. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). In this case, the Board acknowledges that a May 2009 VA examination found, in pertinent part, that the cervical spine had forward flexion to 45 degrees, while the lumbar spine had forward flexion to 90 degrees. Further, there was no change noted with repetitive motion testing. Nevertheless, the Board must find that it does not appear this examination adequately addressed the effect of pain on motion, particularly in light of the requirements for such as detailed in requirements of Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board further notes that it does not appear the Veteran was accorded a competent medical examination which adequately addressed the effect of pain until March 2016. Resolving all reasonable doubt in favor of the Veteran, the Board finds that these examination findings should be presumed to be reflective of the period that is the focus of this appeal. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7. In pertinent part, that examination indicated the cervical spine had an initial forward flexion of 15 degrees, reduced to at least 10 degrees following repetitive motion testing (and presumably during flare-ups). That examination also found the lumbar spine had an initial forward flexion of 70 degrees, reduced to at least 60 degrees following repetitive motion testing (and presumably during flare-ups). Consequently, the Board must conclude that the competent and credible evidence of record reflects that during the period from April 27, 2009, to December 31, 2014, the Veteran’s service-connected cervical spine disorder more nearly approximated than not the criteria of forward flexion limited to 15 degrees or less; and the lumbar spine more nearly approximated than not forward flexion limited to 60 degrees or less. Therefore, he is entitled to a 40 percent rating for the cervical spine during this period, and a 20 percent rating for the lumbar spine. Inasmuch as the Veteran has indicated he is satisfied with the 30 percent evaluation for his cervical spine, and the 20 percent evaluation for his lumbar spine, this decision constitutes a full grant of the benefits sought on appeal with respect to these claims. 3. A rating in excess of 10 percent for service-connected tinnitus The Veteran seeks an increased rating for his service-connected tinnitus, for which he is currently receiving a 10 percent rating under Diagnostic Code 6260. This Code allows for a single 10 percent disability rating for tinnitus regardless of whether it is unilateral or bilateral. Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). No higher disability rating is available under the Rating Schedule. Accordingly, as there is no legal basis upon which to award separate schedular evaluations for tinnitus in each ear or otherwise increase the Veteran's total compensation for his service-connected tinnitus, his claim for an increased rating must be denied. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Service Connection 4. Service connection for compensation purposes for a dental disability manifested by tooth and gum pain Service connection may be awarded for missing teeth due to dental trauma or bone loss in service. The law and regulations also provide that treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are considered non-disabling conditions and may be considered service-connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment. See 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 17.161; see also Woodson v. Brown, 8 Vet. App. 352, 354 (1995). To establish entitlement to service connection for loss of a tooth, the veteran must have sustained a combat wound or other in-service trauma. 38 U.S.C. § 1712; 38 C.F.R. § 3.381(b). The term "service trauma" does not include the intended effects of therapy or restorative dental care and treatment provided during a veteran's active service. See 38 C.F.R. § 3.306 (b)(1); VAOGCPREC 5-97. In this case, the Board acknowledges that the Veteran reported on a December 2005 post-deployment evaluation that he had chipped his tooth during service. As such, it does appear there was evidence of trauma. Nevertheless, service connection for compensation purposes is only warranted for certain dental conditions. Specifically, dental disabilities that may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Although the Veteran has reported tooth and gum pain, a thorough review of his service treatment records and post-service medical records does not reflect he has a dental disability for which compensation may be paid under 38 C.F.R. § 4.150. Further, he has not contended there is outstanding evidence which would demonstrate such a disability. In view of the foregoing, the Board finds that the claim of service connection for compensation purposes for a dental disability must be denied. The Board notes that in making this determination it was cognizant of the fact that the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 are for consideration regarding the Veteran, and they provide service connection may be established for an undiagnosed illness. Nevertheless, as only specified dental disabilities are subject to compensation the Board notes that these provisions would not affect the outcome of this appeal. REASONS FOR REMAND 1. Entitlement to service connection for a bilateral knee disorder is remanded. 2. Entitlement to service connection for an upper respiratory disorder to include sinusitis and/or allergic rhinitis is remanded. 3. Entitlement to service connection for varicose veins is remanded. 4. Entitlement to service connection for a skin rash of the bilateral hands is remanded. 5. Entitlement to service connection for foot fungus, to include tinea pedis, is remanded. 6. Entitlement to service connection for recurrent headaches is remanded. 7. Entitlement to service connection for disability manifested by tingling and numbness of the upper extremities is remanded. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Further, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In addition to the general rules of service connection noted above, the Board acknowledges service connection may also be established for a chronic disability resulting from an undiagnosed illness which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than September 30, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A "qualifying chronic disability" for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C), any diagnosed illness that the Secretary determines in regulation prescribed under subsection (D) warrants a presumption of service connection. 38 U.S.C. § 1117 (a)(2); 38 C.F.R. § 3.317 (a)(2)(i)(B)(1). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). The Veteran has essentially contended that he developed recurrent disabilities while on active duty, either during his deployment to the Southwest Asia Theater of Operations or shortly thereafter. These claimed disabilities include bilateral knee pain; recurrent symptoms of congestion, sneezing, and runny nose; varicose veins; skin problems of the bilateral hands; skin fungus of the bilateral feet; headaches; as well as pain, tingling and numbness of the upper extremities. He maintains he did not have such disabilities prior to deployment. The Board also notes that the Veteran’s service treatment records indicate he complained of pain and numbness of the bilateral shoulders in August 2005. Further, on a December 2005 post-deployment evaluation he reported, in pertinent part, that he was currently experiencing runny nose; weakness; swollen, stiff or painful joints; muscle aches; numbness or tingling in hands or feet. Moreover, except for the runny nose, he indicated he experienced these symptoms during deployment as well. However, he indicated he was not experiencing headache, nor skin diseases or rashes. In addition, he was treated for an upper respiratory infection in December 2005. Despite the foregoing, the nature and etiology of the claimed disabilities is not clear from the evidence of record, to include the potential applicability of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. For example, a June 2006 VA examination noted complaints of bilateral shoulder pain, but there was no functional impairment found on physical examination. Thereafter, a July 2016 VA examination attributed his left arm numbness to radiculopathy of the cervical spine. However, an October 2016 VA examination attributed the complaints to transient brachial plexus. His complaints of upper respiratory problems have been attributed to allergic rhinitis and sinusitis; his left knee to meniscus disease; his right knee to meniscus disease; his right knee to patellofemoral joint disease and degenerative joint disease; and his skin problems to tinea pedis. There are also findings of varicose veins. The Board further notes that there are conflicting medical opinions as to whether such findings are related to service. For example, the July 2016 VA examination related to left arm numbness to the service-connected cervical spine disability; that the left knee was related to service; and the right knee was secondary to the left knee. The October 2016 VA examination opined, in essence, that the bilateral knees, allergic rhinitis, tinea pedis, and varicose veins were “at least as likely as not … related to a specific exposure event experienced by the Veteran during service in Southwest Asia.” However, in a subsequent addendum/clarification the examiner opined that such was not actually the case. Due to the conflicting medical opinions, it is not clear that the pertinent VA examiners had an accurate understanding of the Veteran’s medical history. Moreover, it does not appear these opinions adequately addressed the Veteran’s competent lay testimony of recurrent symptoms which developed during or shortly after his deployment to the Southwest Asia Theater of Operations. In addition, it does not appear he has been accorded an examination which adequately addressed his headaches claim. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, a remand is required to accord the Veteran new competent medical examination(s) which does adequately address the nature and etiology of these claimed disabilities. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (When the medical evidence of record is insufficient, in the opinion of the Board, or of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions.). 8. Entitlement to service connection for hearing loss is remanded. The Veteran has contended that he developed hearing problems during active service as a result of in-service noise exposure, and provided details thereof. Further, the Board notes he provided similar contentions regarding his service-connected tinnitus. For the purpose of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; or when the auditory threshold for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 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. Further, the Court has indicated that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). When audiometric test results at a veteran’s separation from service do not meet the regulatory requirements for establishing a “disability” at that time, he may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley, 5 Vet. App. at 160. Initially, the Board notes that the Veteran was not shown to have a hearing loss disability during service, or on a June 2006 VA audio examination. For example, audio evaluation conducted as part of his January 2003 enlistment examination revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 5 0 0 10 10 LEFT 15 15 5 0 10 15 The June 2006 VA audio examination revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 Average RIGHT 20 15 15 10 10 13 LEFT 25 20 15 10 10 14 Speech recognition scores were 98 percent for the right ear, and 100 percent for the left ear. A February 2016 VA audio examination did demonstrate a hearing loss disability pursuant to 38 C.F.R. § 3.385. Specifically, revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 Average RIGHT 40 45 35 35 40 35 LEFT 25 35 25 40 25 30 Speech recognition scores were 96 percent for both ears. Moreover, that examination included an opinion it was at least as likely as caused by or a result of an event in military service. However, the stated rationale does not appear to be consistent that opinion. A subsequent September 2016 VA medical opinion is against the current hearing loss disability being etiologically related to service. In this case, the Board finds the aforementioned 2016 VA examinations do not appear to adequately address the nature and etiology of the Veteran’s hearing loss. Therefore, a remand is required to accord the Veteran a new examination. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records for the period from December 2015 to the present. 2. Request the Veteran identify all medical care providers who have treated him for his knees, hearing loss, upper respiratory problems, skin problems, varicose veins, and headaches from December 2015 to the present. After obtaining any necessary release, obtain those records not on file. 3. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service his knees, hearing loss, upper respiratory problems, skin problems, varicose veins, and headaches symptomatology. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. The Veteran should be scheduled for a competent medical examination(s) by an appropriately qualified clinician to address the nature and etiology of his claimed disabilities of the knees, upper respiratory system, skin, varicose veins, and headaches. The examiner is asked to review the pertinent evidence, including the Veteran’s lay assertions regarding his symptomatology, and undertake any indicated studies. Then, based on the results of the examination, the examiner is asked to address each of the following questions: (a) Please state whether the symptoms of each claimed condition are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such condition, when did that condition resolve? (b) Is the Veteran’s disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis. (c) If, after examining the Veteran and reviewing the claims file, you determine that the Veteran’s disability pattern is either (2) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis, then please provide an expert opinion as to whether it is related to a presumed environmental exposures experienced by the Veteran during service in Southwest Asia. (d) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War? (e) If not directly related to service on the basis of questions (b)-(d), is any medical condition proximately due to, the result of, or caused by any service-connected disability(ies)? (f) If not caused by another medical condition, has any disorder been aggravated (made permanently worse or increased in severity) by any service-connected disability(ies) ? If yes, was that increase in severity due to the natural progress of the disease? In answering all questions (a) to (f), please articulate the reasons underpinning your conclusions. That is, (1) identify what facts and information, whether found in the record or outside the record, support your opinion, and (2) explain how that evidence justifies your opinion. A report of the examination should be prepared and associated with the Veteran’s VA claims file. 5. The Veteran should also be scheduled for a competent medical examination by an appropriately qualified clinician to address the nature and etiology of his hearing loss disability. The examiner should express an opinion as to whether it is at least as likely as not the current disability was incurred in or otherwise the result of active service. Such an opinion should reflect consideration of the Veteran’s competent lay testimony of in-service noise exposure and recurrent hearing problems originating during service, as well as the threshold shift noted from the time of the January 2003 enlistment examination and the June 2006 VA audio examination. A complete rationale for any opinion expressed should be provided, to include if the examiner determines an opinion cannot be provided without resort to speculation. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD John Kitlas, Counsel