Citation Nr: 21001087 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 14-24 504A DATE: January 7, 2021 ORDER Entitlement to service connection for a low back disorder is denied. Entitlement to service connection for a right knee disorder is denied. Entitlement to service connection for a left knee disorder, claimed as secondary to a right knee disorder, is denied. Entitlement to service connection for a right hip disorder, to include as secondary to a low back disorder, is denied. Service connection for right ear hearing loss is granted. Entitlement to a compensable rating for right great toe onychomycosis is denied. REMANDED Entitlement to a compensable disability rating for left ear hearing loss is remanded. Entitlement to a 10 percent evaluation based upon multiple noncompensable, service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran’s low back disorder is not related to any injury, disease, or event incurred in service. 2. The Veteran’s right knee disorder is not related to any injury, disease, or event incurred in service. 3. The Veteran’s left knee disorder is not related to any injury, disease, or event incurred in service, or to a service-connected disability. 4. The Veteran’s right hip disorder is not related to any injury, disease, or event incurred in service, or to a service-connected disability. 5. The Veteran’s right ear hearing loss had its onset in service. 6. The Veteran’s onychomycosis of the right great toe affects less than five percent of his total body area and his exposed areas, and has not been treated with systemic therapy such as corticosteroids or other immunosuppressive drugs. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disorder have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 2. The criteria for service connection for a right knee disorder have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 3. The criteria for service connection for a left knee disorder have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 4. The criteria for service connection for a right hip disorder have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 5. The criteria for service connection for right ear hearing loss have been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2019). 6. The criteria for entitlement to a compensable rating for onychomycosis have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, Diagnostic Codes 7806, 7820 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1984 to February 1992. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Jurisdiction currently resides with the RO in Louisville, Kentucky. In May 2019, the Veteran testified at a Travel Board hearing conducted with the undersigned Veterans Law Judge. A transcript of the hearing is of record. This claim was previously before the Board in September 2019, at which time it was remanded for further development. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to establish service connection for a disability resulting from a disease or injury incurred in service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Entitlement to service connection for a low back disorder The Veteran was seen for a complaint of low back pain in February 1991. He stated that he was lifting boxes two days earlier and experienced a sharp pain approximately a day afterwards. On his February 1992 separation examination, the Veteran’s spine was noted as “normal,” but the examiner found that he did have back pain. He also reported recurrent back pain on the contemporaneous Report of Medical History. The Veteran stated that he hurt his back in 1989 or 1990, and it bothered him when he did not have back support while sitting. At the May 2019 Board hearing, the Veteran testified that he sought treatment for his back following separation from service but did not begin VA treatment until eight or nine years later. At the time of his hearing, the Veteran was doing tree work and factory work. He further testified that he hurt his back during service, recounting an incident when he was moving artillery and equipment. He felt a pain and could not move, and his platoon leader told him he needed to get checked. Pursuant to the September 2019 Board remand, the Veteran received a VA examination in December 2019 and the examiner noted a diagnosis of degenerative joint disease of the sacroiliac joints. The pain was located in the lower center of his back and radiated down the right side of his hip into the right knee. The Veteran believed he received a profile during service not to exert his back. Based on the results of the examination, the examiner concluded that the Veteran’s condition was less likely than not incurred in or caused by service. The service treatment records showed one episode of back strain after lifting heavy boxes for two days, but the separation examination was normal without fracture and no permanent impairment. Furthermore, there was no treatment other than a few days of light duty and some anti-inflammatory medications. The examiner continued that the etiology of the Veteran’s sacroiliac joint/spinal degenerative joint disease was degenerative in nature with the “wear and tear” of age. Both sides of the joint were affected and multiple levels of the spine, and therefore this was not consistent with a permanent focal trauma to one level but rather consistent with the normal aging process. The examiner concluded that the Veteran’s arthritis was consistent with his age and his work as a landscaper for many years. The Board finds the December 2019 opinion to be highly probative evidence against the Veteran’s claim. The Board finds it to be credible and competent, as the examiner provided a thorough rationale with regards to the Veteran’s low back disability and its lack of connection to service. The examiner highlighted the onset of the Veteran’s low back pain and that the back was normal upon separation. Furthermore, the examiner provided an alternate etiology, noting the onset of the condition was consistent with aging as demonstrated by the fact that both sides of the joint were affected and multiple levels of spine that was inconsistent with a permanent focal trauma to one level. There is also no competent medical opinion evidence that contradicts the opinions of the December 2019 examiner. In light of the competent medical evidence the Board finds that service connection for a low back disorder is not warranted. In arriving at this conclusion, the Board has also considered the statements made by the Veteran relating his low back disorder to service. However, lay evidence can be considered competent and sufficient to establish a diagnosis of a condition when (1) a 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) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)). Here, however, instead of being supported by a later diagnosis by a professional, the only opinion of record is against a relationship between the Veteran’s multi-level degenerative joint disease and service. In addition, while the Veteran is capable of describing the onset of back pain, he is not competent to provide testimony regarding the etiology of his current low back disorder. See Jandreau, 492 F.3d at 1377, n.4. Because these types of disorders are not diagnosed by unique and readily identifiable features, they do not involve a simple identification that a layperson is considered competent to make. Therefore, the statements of the Veteran regarding the claimed etiology of his low back disorder are found to be of less probative value than the competent medical nexus evidence against the claim. Entitlement to service connection for a right knee disorder Entitlement to service connection for a left knee disorder On his February 1992 service separation examination, the Veteran’s lower extremities were noted as normal. On the contemporaneous Report of Medical History, the Veteran denied swollen or painful joints and denied a “tricked” or locked knee. At the May 2019 Board hearing, the Veteran testified that he reported hurting his left knee during service. He could not recall a specific injury but noticed pain in his left knee when he was working in the snow during service. As a result, he injured his right knee by overcompensating to take pressure off of the left. Pursuant to the September 2019 Board remand, the Veteran received a VA examination in December 2019 and the examiner noted a diagnosis of bilateral degenerative arthritis. Following service, the Veteran worked as a labor worker in construction, working outdoors and doing some tree maintenance. He described symptoms of “wear and tear” pain in the right knee, and mildly in the left. It was dull and constant, but the Veteran had not had any physical therapy, injections, or an orthopedic evaluation. Based on the results of the examination, the examiner concluded that the Veteran’s right knee condition was less likely than not incurred in or caused by service. Service treatment records remarked of knee pain during service, but it was diagnosed as an acute strain and the Veteran was given ice, compression, and anti-inflammatory medicine. There was no permanent profile nor was there a restriction due to the right knee condition and he was able to complete service. Current x-rays showed mild decreased spacing bilaterally and some arthritis, but this was a normal finding in a person of the Veteran’s age. The right knee x-ray was also of the same severity as the left knee; there was no indication of laterality or another sign of focal permanent right knee trauma or impairment. The examiner therefore concluded that the etiology was normal wear and tear of aging. The Board finds the December 2019 opinion to be highly probative evidence against the Veteran’s claim. The Board finds it to be credible and competent, as the examiner provided a thorough rationale with regards to the Veteran’s right knee disability and its lack of connection to service. He highlighted the onset of the Veteran’s right knee pain and noted that it was acute and transitory while reaching his conclusion that the disability was less likely as not caused by service. Furthermore, the current x-ray evidence showed that the degeneration in the bilateral knees was nearly identical which would be credible evidence against the Veteran’s claim that he injured his right knee first then injured his left knee as a result of overcompensating. Finally, the examiner provided an alternate etiology, noting the onset of the conditions was consistent with aging. In light of the competent medical evidence the Board finds that service connection for a right and knee disorder is not warranted. As the Board has denied entitlement to service connection for a right knee disorder, entitlement to service connection for a left knee disorder as secondary to a right knee disorder must also be denied. In arriving at this conclusion, the Board has also considered the statements made by the Veteran relating his right knee disorder to service. However, as noted previously, lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)). Here, however, instead of being supported by a later diagnosis by a professional, the only opinion of record is against a relationship between the Veteran’s right knee arthritis and service. In addition, while the Veteran is capable of describing the onset of knee pain, he is not competent to provide testimony regarding the etiology of his current knee arthritis. See Jandreau, 492 F.3d at 1377, n.4. Because these types of disorders are not diagnosed by unique and readily identifiable features, they do not involve a simple identification that a layperson is considered competent to make. Therefore, the statements of the Veteran regarding the claimed etiology of his right knee disorder are found to be of less probative value than the competent medical nexus evidence that is against the claim. Entitlement to service connection for a right hip disorder At the May 2019 Board hearing, the Veteran testified that his right hip condition developed from his low back. He recalled trying to complete his physical evaluation and could not finish because of the pain in his hips when running on the treadmill. Pursuant to the September 2019 Board remand, the Veteran received a VA examination in December 2019 and the examiner noted a diagnosis of bilateral hip degenerative arthritis. He did not recall an injury to his hips while in service but reported a dull, constant pain that was greater in the right hip. It worsened over the years, but he had not sought medical care specifically for his hips. Based on the results of the examination, the examiner concluded that the Veteran’s right hip condition was less likely than not incurred in or caused by service. The service treatment records showed one episode of right hip strain after lifting heavy boxes for two days, but the separation examination was normal without fracture and no permanent impairment. Furthermore, there was no treatment other than a few days of light duty and some anti-inflammatory medications. The examiner continued that the etiology of the Veteran’s degenerative joint disease was degenerative in nature with the “wear and tear” of age. The examiner stated that this was consistent with the bilateral nature of the condition and contrary to focal trauma to one hip versus the other. The examiner concluded that the Veteran’s arthritis was consistent with his age and not with his service 30 years earlier. At the outset, the Board notes that the Veteran is not service connected for a low back disorder, as the claim was previously denied. As such, entitlement to service connection for a right hip disorder as secondary to a low back disorder must be denied. With regards to entitlement to service connection on a direct basis, the Board finds the December 2019 opinion to be highly probative evidence against the Veteran’s claim. The Board finds it to be credible and competent, as the examiner provided a thorough rationale with regards to the Veteran’s right hip disability and its lack of connection to service. He highlighted the onset of the Veteran’s hip pain and the likelihood that the in-service injury was acute and transitory. Furthermore, the examiner provided an alternate etiology, noting the onset of the condition was consistent with aging as demonstrated by the bilateral nature of the degenerative process. In light of the competent medical evidence the Board finds that service connection for a right hip disorder is also not warranted. In arriving at this conclusion, the Board has also considered the statements made by the Veteran relating his right hip disorder to service. However, as noted previously, lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is considered 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) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)). Here, however, instead of being supported by a later diagnosis by a professional, the only opinion of record is against a relationship between the Veteran’s right hip arthritis and service. In addition, while the Veteran is capable of describing the onset of hip pain, he is not competent to provide testimony regarding the etiology of his current hip arthritis. See Jandreau, 492 F.3d at 1377, n.4. Because these types of disorders are not diagnosed by unique and readily identifiable features, they do not involve a simple identification that a layperson is considered competent to make. Therefore, the statements of the Veteran regarding the claimed etiology of his right hip disorder are found to be of less probative value than the competent medical nexus evidence against the claim. Entitlement to service connection for right ear hearing loss Specific to claims for service connection for hearing loss, impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000 or 4000 Hertz is 40 decibels or greater; the threshold for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC test are less than 94 percent. 38 C.F.R. § 3.385 (2019). When there is no diagnosis of hearing loss in service, the absence of documented hearing loss in service is not fatal to a service connection claim for such disability, especially if service records indicate a significant in-service threshold shift. Ledford v. Derwinski, 3 Vet. App. 87 (1992); Hensley v. Brown, 5 Vet. App. 155 (1993). Establishing service connection is possible if the current hearing loss can be adequately linked to service. Ledford, 3 Vet. App.at 89. The Veteran received an audiology consultation in May 2008 and the examiner noted that the Veteran had military, occupational, and recreational noise exposure. His right ear hearing was within normal limits from 250Hz through 1500Hz and sloping to a mild sensorineural hearing loss through 6000Hz. The examiner then found that the Veteran’s military noise exposure was more likely as not a contributing factor to his hearing impairment. The Veteran received a VA examination in November 2008 and reported working around radars and generators during service where he used hearing protection most of the time. Following service, his noise exposure included working in factories and working for a tree service utilizing chainsaws. He stated, however, he wore hearing protection most of the time when at both jobs. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 25 25 25 The Veteran received a VA examination in September 2016. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 35 30 30 35 Speech audiometry revealed speech recognition ability of 72 percent in the right ear. As a result of these findings, the examiner diagnosed right ear sensorineural hearing loss. The examiner did not, however, offer an opinion with regard to its etiology. At the May 2019 Board hearing, the Veteran’s representative noted that the Veteran’s claim was previously denied because an examiner found that his right ear did not meet the auditory thresholds. However, acoustic trauma was conceded. Pursuant to the September 2019 Board remand, the Veteran received a VA examination in December 2019. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 20 30 20 25 Speech audiometry revealed speech recognition ability of 94 percent in the right ear. As a result of these findings, the VA examiner diagnosed the Veteran with right ear sensorineural hearing loss. She then concluded that the hearing loss was less likely as not caused by or a result of an event in service. The Veteran reported noise exposure during service and using hearing protection. His right ear hearing did not decline while on active duty and there was no record of complaint or treatment of the condition in service. The examiner then cited to an Institute of Medicine finding that there was insufficient scientific basis to conclude that permanent hearing loss directly attributable to noise exposure will develop long after noise exposure. Here, the Board finds that the Veteran has impaired bilateral hearing productive of a disability under 38 C.F.R. § 3.385 in the right ear based on the results of the September 2016 VA examination. Thus, the first element of service connection is met with respect to the right ear. Regarding in-service incurrence, as previously stated, the Veteran attributes his hearing loss to in-service acoustic trauma related to his MOS. The Board finds the Veteran’s account of acoustic trauma from radars and generators to be credible and consistent with the circumstances of his service. Because in-service noise exposure is established, the second element of service connection has been met. Turning to the nexus element, the Board acknowledges that the December 2019 VA examiner opined that the Veteran’s hearing loss is not related to military service. The VA examiner’s conclusion is a medical conclusion that the Board cannot ignore or disregard, see Willis v. Derwinski, 1 Vet. App. 66 (1991); however, the Board is free to assess medical evidence and is not compelled to accept a medical opinion. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). The evidence of record otherwise includes lay statements from the Veteran that his hearing loss first began during his active service and has continued ever since. Resolving reasonable doubt in the Veteran’s favor, the Board finds that the Veteran has experienced continuous right ear hearing loss symptoms since service to meet the requirements of presumptive service connection under 38 C.F.R. § 3.303(b). The lay statements from the Veteran further convey that the Veteran first experienced hearing loss in service. Such evidence is sufficient to establish that the Veteran experienced continuity of symptomatology of hearing loss since service. In sum, the Board finds that the evidence is at least in equipoise regarding whether the Veteran’s current right ear hearing loss was incurred in service. Hence, affording him the benefit of the doubt, service connection for right ear hearing loss is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified by the schedule are considered adequate to compensate veterans for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The evaluation of the same “disability” or the same “manifestations” under various diagnoses is prohibited. 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as “such a result would overcompensate the claimant for the actual impairment of his earning capacity.” Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Morgan v. Wilkie, 31 Vet. App. 162 (2019); Fanning v. Brown, 4 Vet. App. 225 (1993). Entitlement to a compensable rating for right great toe onychomycosis The Veteran’s onychomycosis is rated as zero percent disabling under Diagnostic Code 7820. Diagnostic Code 7820 provides that infections of the skin not listed elsewhere in the Rating Schedule are to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801-7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. See 38 C.F.R. § 4.118. Here, Diagnostic Codes 7800 – 7805 are inapplicable, and dermatitis is the predominant disability. The appeal period now before the Board begins in August 2010, which is when service connection went into effect for this condition. See Fenderson v. West, 12 Vet. App. 119 (1999). This disability has been assigned a noncompensable (zero percent) rating throughout the entire appeal period. Significantly, regulations pertaining to skin disabilities were recently amended and new criteria for rating skin disabilities became effective on August 13, 2018. When a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. VAOPGCPREC 3- 2000; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The recently revised skin regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, August 13, 2018. Hence, for the period beginning August 13, 2018, the version more favorable to the veteran will apply. Prior to August 13, 2018 Diagnostic Code 7806 assigns a 10 percent rating when the skin condition covers at least 5 percent, but less than 20 percent of the entire body or exposed areas; or requires intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than 6 weeks during the past 12-month period. A 30 percent rating is assigned when 20 to 40 percent of the entire body or 20 to 40 percent of the exposed areas are affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Higher evaluations are available for more severe manifestations. 38 C.F.R. § 4.118, Diagnostic Code 7806. Since August 13, 2018 Under Diagnostic Code 7806, a noncompensable rating is warranted when no more than topical therapy is required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected, or characteristic lesions involving less than 5 percent of the exposed areas affected. A 10 percent rating is warranted when one of the following exists: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or, intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is warranted when one of the following exists: characteristic lesions involving 20 to 40 percent of the entire body, or 20 to 40 percent of exposed areas are affected; or, systemic therapy including but not limited to corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is warranted when one of the following exists: characteristic lesions involving more than 40 percent of the entire body, or more than 40 percent of exposed areas affected; or, constant or near-constant systemic therapy including but not limited to corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Discussion The Veteran received a VA examination in August 2011 and the examiner noted thinning and discoloration of the right big toe similar to what is seen in onychomycosis of the toenail, but the onychomycosis was 0 percent of the exposed area and less than 1 percent of the total body. At the May 2019 Board hearing, the Veteran testified that his toenail grew slowly with fungus under it. It was hard to wear a shoe or a sock at times because the fungus pushed back on his cuticle, but he would try to cut as much of it off as he could. He described the toenail as very painful and he would have to debride the nail to cut it. The Veteran further testified that the onychomycosis made it painful to walk. Pursuant to the September 2019 Board remand, the Veteran received a VA examination in December 2019 and the examiner noted a diagnosis of tinea pedis of the right great toe. All of the Veteran’s toe pain was from extreme itching and untreated tinea pedis with redness and excoriation at times. He had not been treated with medication in the past 12 months for any skin condition and had not received any treatments or procedures other than systemic or topical medications in the past 12 months for any skin condition. Upon examination, the examiner noted that the Veteran’s dermatophytosis affected less than 5 percent of the total body area and none of the exposed area. His condition did not have any visible characteristic lesions at the time of the examination, but there was erythema and white, flaky skin to the right of the great toe consistent with tinea pedis. There was no scarring of the head, face or neck and no other pertinent physical findings, complications, conditions, signs or symptoms related to his condition. After a thorough review of the record, the Board finds that a higher disability rating is not warranted for the Veteran’s onychomycosis under either version of Diagnostic Code 7806. Under the old regulations, the evidence does not show that the Veteran’s onychomycosis affected at least 5 percent of the entire body or at least 5 percent of the exposed areas affect, or required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. Therefore, the preponderance of the evidence is against the Veteran’s claim of entitlement to a compensable rating for onychomycosis under the regulations in effect prior to August 13, 2018. Under the amended regulations, the evidence does not show that the Veteran’s onychomycosis affected at least 5 percent of the exposed area affected, nor does it show that the Veteran required intermittent systemic therapy. Finally, the evidence does not show that the Veteran required immunosuppressive drugs for a total duration of less than 6 weeks over the past 12-month period. Therefore, the preponderance of the evidence is against the Veteran’s claim of entitlement to a compensable rating for onychomycosis under the old regulations or the amended regulations in effect beginning August 13, 2018. REASONS FOR REMAND Entitlement to a compensable disability rating for left ear hearing loss The initial rating assigned to the Veteran’s left ear hearing loss is inextricably intertwined with the grant of service connection for right ear hearing loss as the ears may now be rated together as bilateral hearing loss. Generally, the RO assigns initial ratings to service-connected disabilities. Therefore, the Board remands the left ear hearing loss rating claim so that the RO may do so for the Veteran’s now service-connected right ear hearing loss. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Entitlement to a 10 percent evaluation based upon multiple noncompensable, service-connected disabilities Finally, the Veteran’s claim of entitlement to a 10 percent disability evaluation for multiple noncompensable service-connected disabilities is inextricably intertwined with the claims granted and remanded for further development. Accordingly, they must be considered together, and thus a decision by the Board on entitlement to a 10 percent disability evaluation for multiple noncompensable service-connected disabilities would at this point be premature. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). The matters are REMANDED for the following action: Issue a rating decision putting into effect the Board’s grant of service connection for right ear hearing loss with consideration of the rating for the already service-connected left ear hearing loss. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Daniels, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.