Citation Nr: 21003014 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 15-20 887 DATE: January 19, 2021 ORDER Service connection for hypertension, to include as secondary to the service-connected posttraumatic stress disorder (PTSD) and/or service-connected anxiety disorder and/or service-connected depression is denied. Service connection for hemorrhoids is granted. A rating in excess of 10 percent for scar of the right leg is denied. A disability rating in excess of 10 percent for status post excision of fibrous dysplasia of the right tibia is denied. A rating in excess of 10 percent for bilateral hearing loss is denied. REMANDED Entitlement to service connection for residuals of a stroke is remanded. Entitlement to service connection for broken and missing teeth is remanded. Entitlement to service connection for incontinence, to include as secondary to the service-connected degenerative disc disease of the lumbar spine is remanded. Entitlement to service connection for left leg paralysis, to include as secondary to the service-connected degenerative disc disease of the lumbar spine is remanded. Entitlement to service connection for right hip pain, to include as secondary to the service-connected status post excision of fibrous dysplasia of the right tibia is remanded. Entitlement to service connection for restless leg syndrome, to include as secondary to the service-connected status post excision of fibrous dysplasia of the right tibia and/or the service-connected neuropathy of the left leg and/or the service-connected degenerative disc disease of the lumbar spine is remanded. Entitlement to service connection for seizures, to include as secondary to the residuals of a stroke is remanded. Entitlement to service connection for blindness of the right eye, to include as secondary to the residuals of a stroke is remanded. Entitlement to service connection for facial/skull scars is remanded. Entitlement to service connection for a bilateral foot disorder, to include toenail fungus (previously claimed as a right foot problem with disfigurement), to include as secondary to the service-connected status post excision of fibrous dysplasia of the right tibia is remanded. Entitlement to service connection for minimal vision of the left eye, to include as secondary to the residuals of a stroke is remanded. FINDINGS OF FACT 1. The Veteran’s hypertension did not have its onset in service or within a year of discharge and was not shown to be related to his active service or caused or aggravated by his service-connected psychiatric disorder. 2. It is at least as likely as not that the Veteran’s hemorrhoids were incurred as a result of service. 3. The evidence of record shows that the Veteran’s right leg scar is superficial, non-linear, and covers an area less than 39 square centimeters; it is painful but not unstable. 4. The preponderance of the evidence is against a finding that the Veteran has impairment from malunion of the right tibia and fibula, with moderate right knee or ankle disability. His right leg flexion has been limited to no less than 130 degrees; his extension has been normal. No right knee recurrent subluxation or lateral instability is shown. He does not have dislocated or symptomatic removal of semilunar cartilage, ankylosis, malunion, or an astragalectomy. 5. At its worse, the Veteran’s bilateral hearing loss is characterized by numeric designation “V” in the left ear and “IV” in the right ear and speech discrimination scores of 76 percent in the left ear and 80 percent in the right ear. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 2. The criteria for entitlement to service connection for hemorrhoids have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.304. 3. The criteria for a disability rating in excess of 10 percent for a service-connected right leg scar are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7804. 4. The criteria for a rating in excess of 10 percent for status post excision of fibrous dysplasia of the right tibia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.40, 4.45, 4.71a, Diagnostic Code 5262. 5. The criteria for a rating in excess of 10 percent for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.85 Diagnostic Code 6100, 4.86. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1987 to October 1989. The Veteran testified before the undersigned Veterans Law Judge during an August 2018 hearing. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) and was remanded by the Board in September 2019. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Certain chronic diseases, such as hypertension, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). An alternative method of establishing the second and third Shedden elements for disabilities identified as chronic diseases in 38 C.F.R. § 3.309(a) is through a demonstration of continuity of symptomatology. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be shown if “the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology.” Savage v. Gober, 10 Vet. App. 488, 498 (1997). In addition, service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Furthermore, service connection may be established on a secondary basis for a disability which is aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 1. Service connection for hypertension, to include as secondary to the service-connected PTSD and/or service-connected anxiety disorder and/or service-connected depression For VA disability purposes, “the term hypertension means that the diastolic blood pressure is predominately 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm.” 38 C.F.R. § 4.104, Diagnostic Code 7101 Note (1). In addition, hypertension or isolated systolic hypertension “must be confirmed by readings taken two or more times on at least three different days.” Id. The Veteran was not diagnosed or treated for hypertension while in service. There is also no indication that his blood pressure during service met the VA definition of hypertension. The Veteran does argue the contrary. In a February 1990 VA treatment record, the Veteran was not diagnosed with, or identified as having a history of, hypertension. The Veteran was not taking blood pressure medication. His blood pressure was measured at 140/84. In a March 1990 VA treatment record, the Veteran’s blood pressure was measured at 108/76. VA treatment records in April 1990 measured the Veteran’s blood pressure at 110/80 and 116/76. In a March 1991 VA examination report, the Veteran’s blood pressure was measured at 102/80. In a November 1991 VA examination report, the Veteran’s blood pressure was measured at 104/60. In a June 2009 evaluation, the Veteran’s blood pressure was measured at 150/90. In January 2011, private treatment records showed the Veteran’s blood pressure was measured at 127/77. In April 2011, private treatment records showed the Veteran’s blood pressure was elevated in several readings; however, the Veteran was not placed on blood pressure medication, nor did any assessment include a diagnosis of hypertension. A May 2011 VA treatment record noted the Veteran’s wife reported the Veteran had hypertension for some time, but that the doctors ignored it. While the physician noted that it was unlikely that severe hypertension would be ignored in a patient with a fresh intracerebral hemorrhage, he did note that the Veteran’s hypertension needed to be addressed. The Veteran’s blood pressure reading was 146/111. The Veteran was started on blood pressure medication and this is the first assessment in the record where hypertension was indicated. At the August 2018 Board hearing, the Veteran argued that his hypertension was secondary to his PTSD. The Veteran was afforded a VA examination for his hypertension in January 2020. The examiner opined that the Veteran’s current hypertension was less likely than not incurred from service based on medical records containing no clinical notes reporting any elevated blood pressure during service which suggested that the Veteran’s current hypertension was not related to service. The examiner also opined that the Veteran’s hypertension was less likely than not incurred within one year post service based on medical records containing no clinical notes of elevated blood pressure within one year post service and the earliest mention of hypertension was in 2011 which suggested current hypertension was not due to service or one year post service. The examiner further opined that the current hypertension that was diagnosed in 2011 was less likely than not due to PTSD based on current medical literature reporting that those with PTSD have a higher risk for hypertension, can cause transient elevated blood pressure, but does not cause permanent hypertension which suggested the Veteran’s current hypertension was not due to service. The examiner opined that the Veteran’s current hypertension was less likely than not aggravated beyond the baseline by PTSD based on medical records that reported hypertension was diagnosed in 2011 with treatment and currently the Veteran was not taking any blood pressure medications. Further, the examiner noted that current medical literature did not show a cause and effect of PTSD on hypertension which suggested that the Veteran’s current hypertension was not aggravated beyond its natural progression by PTSD. Even accepting that the requirements for a diagnosis of hypertension have been met, nothing in the records indicates that the Veteran’s hypertension is directly related to service. Nor has the Veteran stated that it was. Given the long-time delay between service and onset of the Veteran’s hypertension, and the lack of any indication that it was directly caused by service, direct service connection must be denied. Although hypertension is a qualifying chronic disease, the Veteran did not report symptoms of hypertension within one year of service. Nor has the Veteran claimed that he had symptoms of hypertension within one year from service. Accordingly, presumptive service connection is denied. Service connection under the “continuity of symptomatology” theory must also be denied as the Veteran has not reported continuous symptoms of hypertension since service. The weight of the evidence is also against finding secondary service connection to the Veteran’s PTSD. The VA examiner opined that the Veteran’s hypertension was not secondary to his PTSD because the overall literature did not find a causal link between PTSD and hypertension. Secondary service connection for hypertension must be denied. As the weight of the evidence is against the Veteran’s claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Service connection for hypertension must therefore be denied. 2. Entitlement to service connection for hemorrhoids The Veteran contends that his current hemorrhoid condition is related to his active service. In this case, VA treatment records indicate that the Veteran has a current diagnosis of hemorrhoids. In particular, a December 2019 VA examination shows a diagnosis of hemorrhoids. Accordingly, a current disability has therefore been demonstrated. Additionally, the September 2019 Board decision recognized that a personal assault occurred in service that resulted in the Veteran’s current PTSD. As a result, an in-service injury has been shown. An addendum medical opinion regarding the etiology of the Veteran’s hemorrhoid condition was obtained in September 2020. The examiner opined that it was at least as likely as not that the Veteran’s hemorrhoid condition was incurred from sexual assault during service. The examiner stated that the opinion was based on medical records containing psychology notes in May 1987 and June 2011 that reported the Veteran was sexually assaulted as well as medical literature that reported one can acquire hemorrhoids because of sexual assault which suggested current hemorrhoids were due to service. The Board finds that the probative evidence of record indicates that the Veteran’s hemorrhoids are related to his service. The Board finds the September 2020 medical opinion to be probative because it provided an adequate rationale based on the evidence of record. Because the Veteran has a current hemorrhoid condition, and because the probative medical evidence of record indicates that it is at least as likely as not that the Veteran’s hemorrhoid condition is related to his active service, the evidence supports a grant of service connection. The appeal is granted. Increased Rating Ratings for service-connected disabilities are determined by the application of the criteria in VA’s Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The rating schedule is the primary guide in the evaluation of a disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as practicably can be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each disability must be viewed in relation to its history with emphasis on the limitation of activity imposed by the disabling condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice referred to as “staging the ratings.” Fenderson v. West, 12 Vet. App. 119 (1999). 3. A rating in excess of 10 percent for scar of the right leg The Veteran seeks an increased evaluation for his service-connected right leg scar, which is currently rated at 10 percent disabling under 38 C.F.R. § 4.118, Diagnostic Code 7804. Under Diagnostic Code 7804, a 10 percent disability rating is assignable for one or two scars that are unstable or painful. A 20 percent disability rating is assignable for three or four scars that are unstable or painful. A 30 percent disability rating is assignable for five or more scars that are unstable and painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that, if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under Diagnostic Codes 7800, 7801, 7802 or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118. Since Diagnostic Code 7800 relates to burn scar(s) and other disfigurements of the head, face, and neck, its provisions are not applicable in the current matter. Id. Diagnostic Code 7801 assigns a 10 percent disability rating for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq cm) but less than 12 square inches (77 sq cm). A 20 percent disability rating requires an area or areas of at least 12 square inches (77 sq cm) but less than 72 square inches (465 sq cm). A 30 percent disability rating requires an area or areas of at least 72 square inches (465 sq cm) but less than 144 square inches (929 sq cm). A 40 percent disability rating requires an area or areas of 144 square inches (929 sq cm) or greater. A qualifying scar is one that is nonlinear and deep, and is not located on the head, face, or neck. Note (1) to Diagnostic Code 7801 provides that a deep scar is one associated with underlying tissue damage. Id. Under Diagnostic Code 7802, a 10 percent disability rating is assigned for burn scars or scars due to other causes, not of the head, face or neck, that are superficial and nonlinear and have an area or areas of 144 square inches (929 sq cm) or greater. Id. Diagnostic Code 7805 pertains to other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802 and 7804. It specifies that any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-7804 are to be evaluated under an appropriate diagnostic code. Id. The Veteran underwent a VA examination to assess the severity of his service-connected scar in January 2020. The examiner reviewed the claims file and conducted an in-person evaluation, noting the scar on the Veteran’s lower right leg. The examination report reflects the existence of a single painful scar that was tender to the touch. There was no underlying soft tissue damage. Moreover, there were no indications that it was unstable with frequent loss of the covering of skin over the scar. It was measured at 5.5 centimeters by 0.1 centimeters, for an approximate total area of 0.55 square centimeters. Lastly, the examiner concluded that this condition would not affect the Veteran’s ability to work. After careful consideration of the claims file, the Board concludes that the preponderance of the evidence is against finding that the Veteran’s service-connected right leg scar warrants a disability rating in excess of 10 percent. In order to qualify for a 20 percent evaluation under Diagnostic Code 7804, there must be three or four scars that are unstable or painful. Here, although the evidence of record indicates that the Veteran’s service-connected right leg scar is painful, there is still just one. Without anything to support the existence of multiple scars on the Veteran’s right lower extremity, he is not entitled to a higher disability rating under Diagnostic Code 7804. The Board has also considered whether the Veteran’s service-connected right leg scar would warrant separate evaluations under any of the other potentially relevant diagnostic codes. Diagnostic Code 7801 addresses scars that are deep, nonlinear, and at least 39 square centimeters in total area. While it was not clear if the scar on the Veteran’s right lower extremity was nonlinear, it was superficial and had a total area of only 0.55 square centimeters. As such, the Veteran would not be entitled to a separate disability rating under Diagnostic Code 7801. While Diagnostic Code 7802 relates to scars that are superficial and nonlinear, it assigns a single 10 percent evaluation for a scar or scars with a total area of at least 929 square centimeters. Given that the Veteran’s service-connected right leg scar is only 0.55 square centimeters in total area, it likewise would not warrant a separate disability rating under this diagnostic code. Lastly, Diagnostic Code 7805 allows for any disabling effects not considered in a rating provided under Diagnostic Codes 7800-7804 to be evaluated under an appropriate diagnostic code. However, pain is the only residual symptom alleged by the Veteran due to his service-connected right leg scar. Since pain is already considered under the provisions of Diagnostic Code 7804, the Board determines that no further ratings are supported by the evidence of record. In conclusion, the Board finds that the evidence of record does not warrant the assignment of an evaluation in excess of 10 percent for the Veteran’s service-connected right leg scar. To the extent that any higher level of compensation is sought, the preponderance of the evidence is against the claim. Hence the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. 49; 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Accordingly, the Veteran’s claim for a disability rating in excess of 10 percent for his service-connected right leg scar is denied. 4. A disability rating in excess of 10 percent for status post excision of fibrous dysplasia of the right tibia The Veteran appeals for a rating in excess of 10 percent for his status post excision of fibrous dysplasia of the right tibia, which is rated under Diagnostic Code 5262. Under Diagnostic Code 5262, a 10 percent rating is warranted for malunion of the tibia and fibula impairment, with slight knee or ankle disability. A 20 percent rating requires malunion with moderate knee or ankle disability. Based on the evidence, the Board concludes that a rating in excess of 10 percent is not warranted for the Veteran’s status post excision of fibrous dysplasia of the right tibia, including when 38 C.F.R. §§ 4.40, 4.45 are considered. The preponderance of the evidence including the May 2011 and December 2019 VA examination reports are against a finding that this disability results in more than moderate knee or ankle disability. The May 2011 VA examination report shows that the Veteran complained of right lower leg pain but did not report any functional loss. He reported flare-ups but noted these were constant and never went away. His gait was noted as abnormal, but this was due to an unrelated stroke with left hemiparesis. There was no evidence of deformity, malalignment, drainage, tenderness, edema, redness, heat, spasms, painful motion, abnormal movement, guarding of movement, fatigue, lack of endurance, weakness, atrophy, incoordination, instability, or pertinent abnormal weight-bearing. His right knee range of motion was from 0 to 130 degrees, with no additional loss of function or range of motion after 3 repetitions. His right knee muscle strength was normal, and he had no muscle atrophy. The information in the May 2011 VA examination report also shows that additional compensation cannot be assigned under Diagnostic Codes 5256, 5257, 5258, 5259, 5260, 5261, and 5263 as the Veteran does not have right knee instability, ankylosis, a meniscal disorder, or genu recurvatum. Assigning a separate 10 percent rating under Diagnostic Code 5260 while at the same time keeping the 10 percent rating under Diagnostic Code 5262 would be pyramiding, which is prohibited under 38 C.F.R. § 4.14, as both would be compensating for limitation of knee flexion. The December 2019 VA examination report shows that the Veteran reported there were no further symptoms or current treatment. The Veteran denied flare-ups and there was no functional impairment. He had full range of motion and no pain was noted on examination. There was no additional loss of function or range of motion after 3 repetitions. His right knee muscle strength was normal, and he had no muscle atrophy. There was no evidence of ankylosis, recurrent subluxation, instability, or a meniscal disorder. The information in the December 2019 VA examination report also shows that additional compensation cannot be assigned under Diagnostic Codes 5256, 5257, 5258, 5259, 5260, 5261, and 5263 as the Veteran does not have right knee limitation of motion, instability, ankylosis, a meniscal disorder, or genu recurvatum. Therefore, the Board finds that the preponderance of the evidence is against a finding the Veteran’s disability warrants a rating in excess of 10 percent. In this regard, the Board notes that while there are complaints of pain during this period, as well as slight limitation of flexion at the May 2011 VA examination, there was no functional limitation, and there is otherwise no evidence that reflects moderate or marked knee or ankle disability, such as an altered gait due to the status post excision of fibrous dysplasia of the right tibia. 5. A rating in excess of 10 percent for bilateral hearing loss The assignment of a disability rating for hearing impairment is “derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometry evaluations are rendered.” Lendenmann v. Principi, 3 Vet. App. 345, 349 (1993). Specifically, organic impairment of hearing acuity is rated using audiological test results, obtained by a state-licensed audiologist, and the basic rating method involves using both the results of controlled speech discrimination tests (Maryland CNC) and the average decibel threshold level as measured by pure tone audiometry tests at the frequencies of 1000, 2000, 3000, and 4000 Hertz. 38 C.F.R. § 4.85(a). Tests are conducted without hearing aids. Criteria for evaluating hearing loss disabilities provide ratings from 0 (non-compensable) to 100 percent, based on the results of the combined tests. 38 C.F.R. §§ 4.85, Diagnostic Code 6100, 4.86. “Puretone threshold average,” as used in Table VI, is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. Average pure tone decibel loss is located on Table VI along a horizontal axis, and percent of speech discrimination is located along a vertical axis. The axes intersect to determine the Roman numeral designation for hearing impairment in each ear. The results are then matched between the “better” ear and the “poorer” ear on Table VII to produce a disability rating under diagnostic code 6100. When the pure tone threshold at each of the four specified frequencies is 55 decibels or more, either Table VI or Table VIa may be used, whichever is more favorable to the Veteran. 38 C.F.R. § 4.86(a). Additionally, either Table VI or VIa may be used when the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz. Thereafter, the numeric designation will be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). In Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Court held that in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak, 21 Vet. App. at 455. The Court also noted, however, that even if an audiologist’s description of the functional effects of a veteran’s hearing disability was somehow defective, the veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. Id. If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the Veteran shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran was afforded a VA audiology examination in May 2011. The Veteran’s pure tone thresholds for the right ear were 20, 20, 25, and 30 decibels at 1000, 2000, 3000, and 4000 Hertz; the average was 23.75 decibels. Pure tone thresholds for the left ear were 30, 25, 30, and 25 decibels at 1000, 2000, 3000, and 4000 Hertz, respectively, with an average of 27.5 decibels. Speech discrimination scores, using the Maryland CNC word list, were 94 percent for the right ear and 90 percent for the left ear. The examiner opined that the Veteran’s hearing loss had significant effect on the Veteran’s occupation and daily activities due to a hearing difficulty. At the August 2018 hearing, the Veteran reported that he could not hear his phone or other devices without the use of a headset. He further reported that voices and sounds were not as clear as they used to be, essentially testifying that his hearing had gotten worse since his previous examination. The Veteran was afforded another VA audiology examination in December 2019. The Veteran’s pure tone thresholds for the right ear were 55, 40, 55, and 60 decibels at 1000, 2000, 3000, and 4000 Hertz; the average was 52.5 decibels. Pure tone thresholds for the left ear were 60, 55, 65, and 70 decibels at 1000, 2000, 3000, and 4000 Hertz, respectively, with an average of 62.5 decibels. Speech discrimination scores, using the Maryland CNC word list, were 80 percent for the right ear and 76 percent for the left ear. The examiner described the Veteran’s functional impact as difficulty hearing and understanding speech in quiet and in noisy environments. Talking on the phone, taking orders, hearing directions and understanding in meetings or in a classroom setting may all be very challenging. For the December 2019 examination, the objective measurements result in a numeric designation of “IV” for the right ear according to Table VI of 38 C.F.R. § 4.85. Section 4.86 does apply as the Veteran’s pure tone thresholds in the left ear were at or above 55 decibels at each of the 1000, 2000, 3000, and 4000 Hertz levels. 38 C.F.R. § 4.86. The objective measurements result in a numeric designation of “V” for the left ear. According to Table VII, an “IV” numeric designation in the better ear and a “V” numeric designation in the worse ear correspond to a 10 percent disability rating. Thus, the Veteran’s 10 percent rating for hearing is correct and entitlement to a higher evaluation must be denied. REASONS FOR REMAND 1. Entitlement to service connection for residuals of a stroke is remanded. The Veteran has had multiple strokes. The Veteran contends that his strokes are related to or aggravated by his in-service personal trauma. See February 2012 Statement in Support of Claim. The Board notes that to date, no VA examination has been conducted or medical opinion otherwise sought on the cause of the Veteran’s strokes and residuals. The Board finds that the threshold requirements for examination, discussed in McLendon, are met, thus warranting a VA examination. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for broken and missing teeth is remanded. In February 2012, the Veteran stated his claim was seeking service connection for dental care; however, the RO has not developed or adjudicated the issue of service connection for a dental disability on the basis of eligibility for dental treatment and only considered the Veteran’s claim on the basis of service connection for a dental disability for compensation purposes. The Board is unable to proceed with this appeal until the AOJ completes the necessary development and adjudication. 38 C.F.R. § 17.161; Douglas v. Derwinski, 2 Vet. App. 435 (1992); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Therefore, a remand is necessary. 3. Entitlement to service connection for incontinence, to include as secondary to the service-connected degenerative disc disease of the lumbar spine is remanded. The Board finds that a remand is necessary to obtain an addendum opinion to determine whether the Veteran’s incontinence during the pendency of the appeal was related to service and/or was caused or aggravated by his service-connected disabilities, specifically his service-connected back disability. In this regard, pursuant to the September 2019 remand, the Veteran was afforded VA examinations in December 2019. However, the examiner did not provide an adequate opinion. Rather, upon examination, the examiner found that there was no diagnosis of bowel incontinence. This ignores the Veteran’s complaints of bladder incontinence and dismisses treatment for incontinence during the appeal period. Therefore, the examiner is advised that the Veteran has a current diagnosis of incontinence as the Veteran was diagnosed with such during the pendency of the claim, even if it has resolved. See McClain v. Nicholson, 21 Vet. App. 319 (2007). Thus, the Board finds that a remand is necessary to obtain an addendum opinion that addresses such concerns. 4. Entitlement to service connection for left leg paralysis, to include as secondary to the service-connected degenerative disc disease of the lumbar spine is remanded. The Board finds that a remand is necessary to obtain an addendum opinion to determine whether the Veteran’s left leg paralysis during the pendency of the appeal was related to service and/or was caused or aggravated by his service-connected disabilities, specifically his service-connected back disability. In this regard, pursuant to the September 2019 remand, the Veteran was afforded VA examinations in December 2019. However, the examiner did not provide an adequate opinion. Rather, upon examination, the examiner found that there was no diagnosis of external cutaneous nerve paralysis. This ignores the Veteran’s diagnosis of left leg paralysis during the appeal period. Therefore, the examiner is advised that the Veteran has a current diagnosis of left leg paralysis as the Veteran was diagnosed with such during the pendency of the claim, even if it has resolved. See McClain v. Nicholson, 21 Vet. App. 319 (2007). Thus, the Board finds that a remand is necessary to obtain an addendum opinion that addresses such concerns. 5. Entitlement to service connection for right hip pain, to include as secondary to the service-connected status post excision of fibrous dysplasia of the right tibia is remanded. 6. Entitlement to service connection for restless leg syndrome, to include as secondary to the service-connected status post excision of fibrous dysplasia of the right tibia and/or the service-connected neuropathy of the left leg and/or the service-connected degenerative disc disease of the lumbar spine is remanded. 7. Entitlement to service connection for seizures, to include as secondary to the residuals of a stroke is remanded. 8. Entitlement to service connection for blindness of the right eye, to include as secondary to the residuals of a stroke is remanded. 9. Entitlement to service connection for facial/skull scars is remanded. 10. Entitlement to service connection for a bilateral foot disorder, to include toenail fungus (previously claimed as a right foot problem with disfigurement), to include as secondary to the service-connected status post excision of fibrous dysplasia of the right tibia is remanded. 11. Entitlement to service connection for minimal vision of the left eye, to include as secondary to the residuals of a stroke is remanded. The Veteran was afforded VA examinations for his right hip disability, restless leg syndrome, right eye disability, facial/skull scars, bilateral foot disorder, and left eye disability in December 2019. The examiner opined that these disabilities were due to the Veteran’s stroke. Further, the Veteran raised the issue of entitlement to service connection for seizures as secondary to residuals of a stroke. As the claims for service connection for right hip disability, restless leg syndrome, right eye disability, facial/skull scars, bilateral foot disorder, left eye disability and seizures secondary to the residuals of a stroke are inextricably intertwined with the claim for service connection for residuals of a stroke, remand of the claim is also required. See e.g. Harris v. Derwinski, 1 Vet. App. 180,183 (1991). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and cause of the Veteran’s strokes. The examiner should review the Veteran’s claims file and provide the following opinions: (a.) Whether it is at least as likely as not (50 percent greater probability) that any current residuals of a stroke had its onset during service or was otherwise causally related to service, to include any symptomatology, event, or in-service incident, to include the circumstances surrounding his in-service personal trauma and his report of being hit to the point of losing consciousness. (b.) Whether the stroke was caused by OR is or has been aggravated by his service-connected psychiatric disorders. If aggravation is found, the examiner should attempt to quantify the additional disability resulting from aggravation, to include by identifying, to the extent possible, the baseline level of disability prior to aggravation. 2. Obtain addendum VA medical opinions to address the Veteran’s claims for service connection for incontinence and left leg paralysis. Whether or not it is necessary to schedule the Veteran for a subsequent examination is left to the discretion of the new examiner. The examiner must review the claims file and respond to each of the following: (a.) Determine whether the Veteran has a diagnosis of incontinence at any time during the appeal period. (b.) Opine whether it is at least as likely as not that any incontinence is related to or had its onset during service. (c.) Opine whether it is at least as likely as not that the Veteran’s incontinence is related to or had its onset during service and/or was caused or aggravated by a service-connected condition, specifically his service-connected back condition. The examiner must discuss whether the Veteran has a current diagnosis of incontinence. The examiner must also consider that the Veteran was diagnosed with incontinence during the appeal period. The examiner should indicate whether such was originally diagnosed in error, or whether they in fact existed, but resolved. If they were diagnosed in error, the examiner should explain how he/she reached this conclusion. (d.) Determine whether the Veteran has a diagnosis of left leg paralysis at any time during the appeal period. (e.) Opine whether it is at least as likely as not that any left leg paralysis is related to or had its onset during service. (f.) Opine whether it is at least as likely as not that the Veteran’s left leg paralysis is related to or had its onset during service and/or was caused or aggravated by a service-connected condition, specifically his service-connected back condition. The examiner must discuss whether the Veteran has a current diagnosis of left leg paralysis. The examiner must also consider that the Veteran was diagnosed with left leg paralysis during the appeal period. The examiner should indicate whether such was originally diagnosed in error, or whether they in fact existed, but resolved. If they were diagnosed in error, the examiner should explain how he/she reached this conclusion. 3. Complete the necessary development for the dental treatment claim, to include referring it to VHA if deemed necessary. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kelly A. Gastoukian 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.