Citation Nr: 21065280 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 17-02 408 DATE: October 25, 2021 ORDER The appeal of the issue of entitlement to nonservice-connected pension is dismissed. The appeal of the issue of entitlement to service connection for tinnitus is dismissed. Entitlement to service connection for rheumatoid arthritis is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left ankle disability is denied. Entitlement to service connection for a left foot disability is denied. Entitlement to service connection for bilateral hearing loss is denied. REMANDED Entitlement to an initial rating in excess of 10 percent for chronic lumbar strain with degenerative disc disease and spinal fusion prior to December 3, 2016, and in excess of 20 percent thereafter, is remanded. Entitlement to an initial compensable rating for lipomas, bilateral upper and lower extremities, is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. FINDINGS OF FACT 1. In August 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to nonservice-connected pension. 2. In August 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for tinnitus. 3. Rheumatoid arthritis was not shown as chronic in service and did not manifest to a compensable degree within one year of separation from service; continuity of symptomatology is not established; and the most probative evidence establishes that any current rheumatoid arthritis is not otherwise etiologically related to an in-service injury or disease. 4. The most probative evidence establishes that the appellant does not currently have a right knee disability which manifested during active duty or is otherwise causally related to his active service. 5. The most probative evidence establishes that the appellant does not currently have a left ankle disability which manifested during active duty or is otherwise causally related to his active service. 6. The most probative evidence establishes that the appellant does not currently have a left foot disability which manifested during active duty or is otherwise causally related to his active service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the pending appeal of the claim of entitlement to nonservice-connected pension have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for tinnitus have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for entitlement to service connection for rheumatoid arthritis have not been met. 38 U.S.C. §§ 1110; 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 4. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110; 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 5. The criteria for entitlement to service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1110; 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 6. The criteria for entitlement to service connection for a left foot disability have not been met. 38 U.S.C. §§ 1110; 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the U.S. Army from February 1983 to March 1994. This matter comes before the Board of Veterans' Appeals (Board) from a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which, in pertinent part, awarded entitlement to service connection for chronic lumbar strain with degenerative disc disease and assigned an initial 10 percent rating, effective May 31, 2012, and awarded entitlement to service connection for lipomas, bilateral upper and lower extremities, and assigned an initial noncompensable rating, effective May 31, 2012. Entitlement to service connection was denied for bilateral hearing loss, rheumatoid arthritis, right knee disability, left ankle disability, residuals of left foot strain of medial arch, tinnitus, and adjustment disorder with mixed features. Entitlement to pension benefits was also denied. The appellant filed a timely Notice of Disagreement (NOD), received in January 2014. A December 2016 rating decision increased the initial rating of chronic lumbar strain with degenerative disc disease and spinal fusion to 20 percent, effective December 3, 2016. Although a higher rating was granted, the issue remains in appellate status, as the maximum schedular rating was not assigned for the entire period on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Service connection for residual scars of lipomas of the bilateral forearms was also granted in the December 2016 rating decision, and an initial noncompensable rating, effective May 31, 2012, was assigned. Such constitutes a full award of the benefit sought on appeal with respect to that claim. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). A Statement of the Case (SOC) was issued in December 2016. A timely substantive appeal was received in January 2017. The appellant was afforded a virtual hearing before the undersigned Veterans Law Judge (VLJ) in April 2021. A transcript is of record. Withdrawal of Claims 1. Entitlement to nonservice-connected pension. 2. Entitlement to service connection for tinnitus. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 19.55(a). Received on June 22, 2021, was a statement from the appellant's attorney which stated that the appellant wished to withdraw the claims of entitlement to nonservice-connected pension and entitlement to service connection for tinnitus. The withdrawal was in writing, included the name of the appellant, the file number, and a clear statement that the claims withdrawn. See Hembree v. Wilkie, 33 Vet. App. 1 (2020). Thus, the criteria for a withdrawal of the claims of entitlement to nonservice-connected pension and entitlement to service connection for tinnitus have been met and there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the claims and they are dismissed. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. "To establish a right to compensation for a present disability, a Veteran 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'the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 3. Entitlement to service connection for rheumatoid arthritis. The Board finds that the most probative evidence is against the award of entitlement to service connection for rheumatoid arthritis. While service treatment records include notations of injuries and joint pain, as detailed below with respect to the lower extremities, there is no probative evidence that arthritis was noted in service with continuity of symptomatology since service that is attributable to the chronic disease, nor is there any indication that arthritis manifested to a compensable degree within one year of service separation. Rather, the appellant's service treatment records are silent for complaints, diagnosis, or treatment related to rheumatoid arthritis. The appellant's September 1993 separation examination revealed that the appellant's neck, spine, upper and lower extremities, and feet, and entire musculoskeletal system, were essentially normal. On the accompanying Report of Medical History, the appellant reported that he was in fair health. He endorsed having, or having had, swollen or painful joints, bone, joint, or other deformity, painful or "trick" shoulder or elbow, recurrent back pain, and foot trouble but specifically denied having, or having had, broken bones, arthritis, rheumatism, or bursitis, or "trick" or locked knee. A July 2012 VA telephonic note states that the appellant reported that his legs gave out suddenly and he fell and hit his wrists and knees. A December 2012 VA clinical note states that the appellant reported generalized joint pain including in the knees and ankles which began three months ago but denied a history of trauma. Examination revealed full range of motion of all joints. The assessment was polyarthralgia, likely related to low testosterone, although the VA clinician noted that rheumatoid arthritis was a consideration given the appellant's family history. In April 2013, range of motion of all joints was again full. July 2013 imaging studies of the left ankle and foot were essentially normal. The appellant complained of left knee swelling following an August 2013 fall down the stairs. The appellant was afforded a contracted non-degenerative arthritis examination in December 2016. The claims file was reviewed. The appellant reported that he began to experience pain in the bilateral wrists in 1989 and that such had progressed since then. He endorsed swelling of the bilateral wrists and hands, which makes it difficult to hold onto objects. The current rheumatoid factor based on November 2016 lab work was normal. Following examination of the appellant and review of the claims file, the clinician determined that there was no pathology upon which to render a diagnosis. During the April 2021 Board hearing, the appellant's attorney stated that the original claim of service connection was for arthritis and that she was unsure when the claim became for rheumatoid arthritis. She reported that she had spoken with the appellant on this topic and it was confirmed that the appellant had degenerative arthritis and not rheumatoid arthritis. She also stated that the claim regarding arthritis was with respect to the back and should be regarding degenerative arthritis and not rheumatoid arthritis. The attorney agreed that the appellant did not have rheumatoid arthritis or a systemic arthritis disability. Rather, service connection was already in effect for a back disability and at issue was the proper disability rating. However, the attorney stated that she did not necessarily want to withdraw the claim of service connection for rheumatoid arthritis in case a separate rating would be available. The attorney was advised to clarify her contentions regarding rheumatoid arthritis in writing within the next 60 days. In the appellant's attorney's June 2021 brief, it is stated that: The Veteran suffers from degenerative arthritis not rheumatoid arthritis as part of his back condition. Please see the prior section of this document for information regarding the Veteran's back conditions and diagnostic criteria. The appellant's attorney did not explicitly withdraw the issue of service connection for rheumatoid arthritis in her brief, but simply directed attention to her contentions regarding the issue of entitlement to an initial rating in excess of 10 percent for chronic lumbar strain with degenerative disc disease and spinal fusion prior to December 3, 2016, and in excess of 20 percent thereafter. All such contentions in that section were about the proper initial rating for such. However, also received in June 2021 from the appellant's attorney were records from Saint Anthony Medical Center, which include a January 2021 diagnosis of rheumatoid arthritis without rheumatoid factor, multiple sites. Such was described as Factor V Leiden mutation. Received in July 2021 was an April 2021 statement from A.P.R., M.D., in response to a request for diagnosis of the appellant's neck and back pain. Dr. A.P.R. reported that the appellant had, inter alia, rheumatologic joint disorder. However, no etiological opinion was offered. To the extent that such is a reference to the attorney's statements during the April 2021 hearing as to the proper diagnosis of the service-connected back disability, the Board notes that the issue of entitlement to an initial rating in excess of 10 percent for chronic lumbar strain with degenerative disc disease and spinal fusion prior to December 3, 2016, and in excess of 20 percent thereafter, is being remanded, as discussed in further detail below. The Board observes that, during an April 2021 mental health visit with a VA social worker, the appellant stated that VA had lost his records and had told him that they had no record of the appellant's medals or service in Iraq. He also reported during a May 2021 psychiatric visit that he found crews shot up in tanks while in Iraq. However, there is no indication, aside from the appellant's lay contentions, that he served in Iraq. Service treatment and personnel records do not support a finding that the appellant served in Iraq. Further, there is no indication, aside from the appellant's lay contentions, that his service treatment records are incomplete. The appellant's attorney has not provided any argument on this matter. The Board thus finds that the appellant's reports of having served in Iraq are not credible and, as such, consideration of the presumptions of service connection for veterans who served in the Southwest Asia theater of operations is not warranted. The Board's conclusion is strengthened by having had the opportunity to observe his demeanor at a hearing. Although there are clinical notes which include diagnoses of rheumatoid arthritis, there is no indication that any current rheumatoid arthritis was incurred in or is otherwise causally related to the appellant's active service. As noted above, there is no indication, nor is it contended, that rheumatoid arthritis manifest to a compensable degree within one year of separation. Thus, service connection on a presumptive basis is not for application. 38 C.F.R. §§ 3.307, 3.309. In fact, the nature of the appellant's theory of entitlement with respect to this claim is unclear. The appellant's attorney stated during the April 2021 Board hearing that the claim should have been for degenerative arthritis and not rheumatoid arthritis. The attorney was advised to supplement her arguments with a written brief. In the June 2021 brief, the attorney repeated the statement that the appellant had degenerative arthritis and not rheumatoid arthritis, and only provided argument as to the proper rating for the appellant's service-connected back disability. The appellant and his attorney have been given multiple opportunities to submit or identify evidence or arguments in support of the claim of service connection for rheumatoid arthritis, but apparently chose not to do so. The appellant's attorney is reminded that it is a claimant's responsibility to support a claim for VA benefits, including submitting or specifically identifying relevant evidence and alleging specific errors of fact or law. See 38 U.S.C. §§ 5107(a), 7105(d)(5). Counsel are expected to present arguments they deem material and relevant to their clients' cases. See e.g. Andrews v. Nicholson, 421 F.3d 1278, 1282 (Fed. Cir. 2005) (pro se pleadings, not those of counsel, are entitled to a sympathetic reading). The notations of a diagnosis of rheumatoid arthritis in the medical records submitted after the Board hearing appear to have escaped the appellant's attorney's attention. In any event, however, there is no indication that any current rheumatoid arthritis was incurred in or is otherwise causally related to an in-service injury or disease. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 4. Entitlement to service connection for a right knee disability. 5. Entitlement to service connection for a left ankle disability. 6. Entitlement to service connection for a left foot disability. The Board finds that the preponderance of the evidence is against the award of entitlement to service connection for a right knee disability, a left ankle disability, or a left foot disability. Service treatment records reveal that the appellant was treated for athlete's foot in June 1984 and April 1986. He stepped on a thumb tack in May 1986 and examination revealed no obvious deformity and that the wound was healing. The appellant incurred a left ankle injury in September 1987 and was placed in a cast. In May 1987, the appellant scraped and injured his right leg during baseball. He complained of pain swelling after walking on it all day. Examination revealed full range of motion of the foot and ankle. Moderate swelling and abrasions over the middle third of the anterior tibia were noted. The appellant incurred a left foot injury when the stepped on a rock. He was assessed with medial arch ligament sprain. A September 1987 imaging study of the left foot was negative for osseous abnormality. He had been seen previously in the month for an infected left foot, when he was assessed with resolving cellulitis. An October 1987 clinical note states that the appellant had left plantar fasciitis. Range of motion was full and podiatry would be consulted regarding a possible orthotic. His left ankle cast was removed later in October 1987. During a periodic medical examination conducted in April 1988, the appellant's lower extremities and feet were examined and found to be essentially normal. The appellant incurred a left ankle injury playing basketball on March 2, 1992, when he fell and the ankle was stepped on. He was assessed with a grade II left ankle sprain. A March 4, 1992, imaging study of the left ankle revealed no fracture, dislocation, or other focal bony abnormality. Ankle mortice was symmetrical. The appellant's September 1993 separation examination revealed that the appellant's lower extremities and feet were essentially normal. On the accompanying Report of Medical History, the appellant reported that he was in fair health. He endorsed having, or having had, swollen or painful joints, bone, joint, or other deformity, painful or "trick" shoulder or elbow, recurrent back pain, and foot trouble. The appellant denied having, or having had, broken bones, arthritis, rheumatism, or bursitis, or "trick" or locked knee. A July 2012 VA telephonic note states that the appellant reported that his legs gave out suddenly and he fell and hit his wrists and knees. A December 2012 VA clinical note states that the appellant reported generalized joint pain including in the knees and ankles began three months ago but denied a history of trauma. Examination revealed full range of motion of all joints. The assessment was polyarthralgia, likely related to low testosterone, although the VA clinician noted that rheumatoid arthritis was a consideration given the appellant's family history. In April 2013, range of motion of all joints was again full. July 2013 imaging studies of the left ankle and foot were essentially normal. The appellant complained of left knee swelling following an August 2013 fall down the stairs. The appellant was afforded VA knee, ankle, and foot examinations in July 2013. The claims file was reviewed. Regarding the right knee, the appellant denied any history of a knee injury and denied any current knee problems. The VA examiner noted that service treatment records were negative for any history of knee injury. Following examination of the appellant and review of the claims file, the VA examiner determined that there was no pathology upon which to render a diagnosis of the right knee. Further, there was no functional impairment of the right knee. With respect to the left ankle and left foot, the appellant reported an acute left foot strain of the medial arch in 1987 after stepping on a rock. This injury resolved shortly after it occurred and the appellant denied any problems with the left foot since that time and the appellant also denied any history of injury to either ankle. Following examination of the appellant and review of the claims file, the VA examiner determined that there was no pathology upon which to render a diagnosis of the left ankle or left foot. Further, there was no functional impairment of the left ankle or left foot. Although imaging studies of the left knee reveal mild degenerative changes, see e.g. July 2013 note from SwedishAmerican Hospital, there is no current disability, or functional impairment in earning capacity, with respect to the right knee, for which service connection has been claimed. During a June 2018 VA hip and thigh examination in connection with a claim of service connection for a right leg disability, the appellant reported that he used to get aching in his legs and knees while on road marches in service. Eventually, he underwent back surgery, was diagnosed with a blood disorder, and developed deep vein thrombosis. He also reported that he falls a lot due to his knees. Following examination of the appellant and review of the claims file, the VA clinician determined that there was no pathology upon which to render a diagnosis and that the appellant experienced no functional impairment. In the attorney's June 2021 brief, it was noted that service treatment records were "replete with complaints of back, knee, and ankle pain." The attorney also noted that the appellant "was deployed to Kosovo and was under fire often while retrieving vehicles." As discussed below with respect to the claim of service connection for an acquired psychiatric disorder, the Board finds that the appellant's reports of serving in Kosovo and being under fire are not credible. The appellant's service treatment and personnel records do not support a conclusion that he served in Kosovo. The Board also observes that the appellant separated from active service in March 1994. The Board further takes judicial notice of the fact that United States Army involvement in Kosovo did not occur until 1999. See e.g. https://history.army.mil/brochures/Kosovo/Kosovo.pdf (last accessed 5 October 2021). The Board thus finds that the appellant's reports of having served in Kosovo are not credible. The Board's conclusion is strengthened by having had the opportunity to observe his demeanor at a hearing. In any event, such is irrelevant because, as delineated above, the most probative evidence establishes that the appellant does not have a current right knee, left ankle, or left foot disability, or any functional impairment in earning capacity. The Board has considered the appellant's lay history of symptomatology related to his claimed disorder throughout the appeal period. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through an individual's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The appellant in this case is not competent to diagnose on his own or to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant in this case, who has not been shown by the evidence of record to have medical training or skills. The Board finds the VA examination reports to be of greater probative weight than the appellant's lay assertions. In any event, as noted above, the appellant himself denied current right knee, left ankle, or left foot symptoms during the July 2013 VA examinations. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1131. Thus, where the collective lay and medical evidence indicates that, fundamentally, the appellant does not have a current disability for which service connection is sought, there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gilpin v. West, 155 F.3d 1353, 1356 (Fed. Cir. 1998). The Board notes that "disability" as defined in 38 U.S.C. §§ 1110 and 1131 refers to the functional impairment of earning capacity, not the underlying cause of said disability, and that pain alone can reach the level of a functional impairment of earning capacity. Saunders v. Wilkie, 866 F.3d 1356 (2018). In this case, however, there is no indication, nor is it contended, that the appellant experiences any right knee, left ankle, or left foot symptoms which cause a functional impairment in earning capacity. In summary, the Board finds that the most probative evidence shows that the appellant does not currently have right knee, left ankle, or left foot disabilities and the record contains no indication that any currently claimed right knee, left ankle, or left foot disabilities were incurred in active service or is otherwise causally related to active service. Thus, the claims of service connection for right knee, left ankle, and left foot disabilities must be denied at this time. See 38 C.F.R. §§ 3.102, 3.303; McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary's adjudication of the claim."); Brammer, supra. As the evidence preponderates against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 10 percent for chronic lumbar strain with degenerative disc disease and spinal fusion prior to December 3, 2016, and in excess of 20 percent thereafter. The Board finds that the most recent February 2019 contracted back examination is inadequate. The examiner was unable to determine whether the examination was medically consistent or inconsistent with the appellant's statements regarding functional loss following repeated use over time or during flare-ups. Additionally, the examiner was unable to determine whether pain, weakness, fatigability, and/or incoordination significantly limited functional ability with flare-ups without resort to mere speculation and failed to provide a range of motion (ROM) assessment of the appellant's disability following repeated use over time or during flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). As such, the appellant should be afforded a new examination to determine the severity and manifestations of his service-connected lumbar spine disability. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Entitlement to an initial compensable rating for lipomas, bilateral upper and lower extremities. Since the appellant's April 2021 contracted examinations regarding his service-connected lipomas of the bilateral upper and lower extremities, the appellant underwent removal of lipomas in June 2021. See June 2021 attorney's brief. As such, it appears that the appellant's service-connected disability may have worsened in severity since the April 2021 examination, in that additional surgical intervention was needed and performed. Further, there may be additional surgical scars from the procedures now. As it appears that the appellant's service-connected lipomas increased in severity since the last compensation and pension examination conducted in April 2021, the Board finds that the appellant should be afforded a new examination to assess the severity and manifestations of his service-connected lipomas, bilateral upper and lower extremities. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). 3. Entitlement to service connection for an acquired psychiatric disorder. The appellant was afforded a VA psychiatric examination in July 2013. The claims file was reviewed. Following examination of the appellant and review of the claims file, adjustment disorder with mixed features was diagnosed under DSM-IV criteria. The VA psychologist offered a negative etiological opinion, based in large part on the appellant's own reports that his current symptoms were the result of more recent, post-service, situational stressors. Received in June 2021 was an April 2021 opinion of Z.G., a Certified Clinical Military Counselor. Other specified trauma and stressor-related disorder was diagnosed under DSM-5 criteria. Z.G. offered a positive etiological opinion. However, this opinion is insufficient to warrant a grant of the benefits sought. Indeed, it is based in part upon the appellant's reports of having had active service in Kosovo where he was under fire. The appellant's service treatment and personnel records do not support his report to Z.G. during the April 2021 examination that he served in Kosovo. The Board also observes that the appellant separated from active service in March 1994. The Board further takes judicial notice of the fact that United States Army involvement in Kosovo did not occur until 1999. See e.g. https://history.army.mil/brochures/Kosovo/Kosovo.pdf (last accessed 5 October 2021). The Board thus finds that the appellant's reports of having served in Kosovo are not credible. The Board's conclusion is strengthened by having had the opportunity to observe his demeanor at a hearing. However, the Board makes no further credibility findings at this time regarding this claim. In any event, however, the April 2021 opinion is based upon an inaccurate factual premise. Since the July 2013 VA examination, the appellant has received VA mental health treatment and has attributed symptoms to his active service. Indeed, a May 2021 VA psychiatry note states that the appellant was assessed with PTSD. However, this diagnosis was not based upon a verified stressor. Rather, it was based solely on the appellant's lay history provided during the instant visit. The Board notes that mere transcription of lay history as reported by a veteran, unenhanced by any additional comment by that examiner, does not become competent medical evidence merely because the transcriber is a medical professional. See LeShore v. Brown, Vet. App. 406, 409 (1995). Despite the inadequacies identified above, the April 2021 opinion and May 2021 VA psychiatric note suggest that at least some of the appellant's psychiatric symptoms are causally related to his active service, or pain from service-connected disabilities, even if such was not the case at the time of the July 2013 VA examination. Additionally, since the July 2013 VA psychiatric examination was conducted, VA amended 38 C.F.R. § 4.125(a) to indicate that a diagnosis of a mental disorder, to include PTSD, must conform to the standards set in the DSM-5. The amendments are applicable to the appellant's claim. See 38 C.F.R. § 4.125; 79 Fed. Reg. 45,093, 45,094-096 (Aug. 4, 2014); 80 Fed. Reg. 14,308 (Mar. 19, 2015) (final) (providing that for claims that were initially certified for appeal to the Board, the Court of Appeals for Veterans Claims (CAVC), or the U.S. Court of Appeals for the Federal Circuit prior to August 4, 2014, DSM-IV will apply. For all applications for benefits received by VA or pending before the AOJ on or after August 4, 2014, DSM-5 will apply). As the appellant's claim was certified on appeal in January 2017, DSM-5 applies to his claim. As such, the Board finds that remand is warranted to afford the appellant a new psychiatric examination. 4. Entitlement to service connection for bilateral hearing loss. The Board finds that remand of the issue of entitlement to service connection for bilateral hearing loss is warranted in order to obtain an addendum opinion. Although the July 2013 VA audiologist's medical opinion was based upon military noise exposure having been conceded, the audiologist appears to have mixed up the left and right ears, at least with respect to the June 1982 entrance examination. It is unclear whether the remainder of the audiologist's opinion and rationale was consistent with this mistake. Indeed, in the July 2013 opinion, the audiologist stated that, upon entry onto active duty in June 1982, audiological testing revealed mild loss, AS (left ear), and within normal limits, AD (right ear). However, the June 1982 enlistment examination report reveals the opposite: HERTZ 500 1000 2000 3000 4000 RIGHT 35 35 35 25 35 LEFT 5 5 15 10 10 The VA audiologist goes on to explain that hearing at separation in December 1993 was within normal limits, AD (right ear), and a normal to mild loss, AS (left ear). Thus, no threshold shifts occurred from enlistment to separation and in fact thresholds got better (AS) at separation at many frequencies. During the appellant's December 1993 separation examination, pure tone threshold testing revealed: HERTZ 500 1000 2000 3000 4000 RIGHT 20 10 15 10 0 LEFT 20 15 30 25 20 When the June 1982 and December 1993 pure tone threshold testing results are compared, right ear hearing acuity improved at each frequency, between 15 and 35 decibels each. Left ear hearing acuity decreased at each frequency. However, no decrease was greater than 15 decibels. There is an improvement between the June 1982 right ear pure tone thresholds when compared to either the right or left ear pure tone thresholds measured in December 1993. Thus, regardless of whether the VA audiologist correctly identified the right and left ears with respect to the December 1993 audiogram, the conclusion that hearing acuity improved between enlistment and separation is correct. However, when the left ear June 1982 thresholds are compared to the right ear December 1993 thresholds, 500 Hz increased by 15 dB, 1000 Hz increased by 5 dB, there was no change to 2000 or 3000 Hz, and 4000 Hz improved by 10 dB. But if the left ear June 1982 thresholds are compared to the left ear December 1993 thresholds, 500, 2000, and 3000 Hz increased by 15 dB each, and 1000 and 4000 Hz increased by 10 dB each. While the largest threshold shift would be 15 dB regardless, it is unclear whether 15 dB threshold shifts at three frequencies, as opposed to one, would constitute a significant threshold shift. Due to the confusion arising from the July 2013 VA audiologist's mix-up of which ear is which on the June 1982 enlistment examination report, the Board finds that a new medical opinion should be obtained regarding the nature and etiology of the appellant's hearing loss. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. Afford the appellant a VA medical examination to determine the current severity of his service-connected lumbar spine disability. Access to the claims file must be made available to the examiner for review in connection with the examination. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the appellant's disabilities under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups and following repeated use over time. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the appellant's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 2. Afford the appellant a VA medical examination to determine the current severity of his service-connected lipomas, bilateral upper and lower extremities. Access to the claims file must be made available to the examiner for review in connection with the examination. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the appellant's disabilities under the rating criteria. 3. Afford the appellant an appropriate examination to determine the nature and etiology of any current psychiatric disability. Access to the appellant's claims file must be made available to the examiner for review in connection with the examination. After reviewing the record and examining the appellant, the examiner should delineate all current psychiatric disabilities exhibited by the appellant, if any. If PTSD is diagnosed, the examiner should specify the stressor(s) upon which the diagnosis is based, to include whether the stressor is related to a fear of hostile miliary or terrorist activity. If any other psychiatric disability is diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not that such disability identified is causally related to the appellant's active service. Diagnoses should be rendered in accordance with DSM-5 and a rationale for all opinions expressed must be provided. In providing the requested opinions, the clinician should review the relevant evidence of record, including the July 2013 VA psychiatric examination report and opinion, the April 2021 private opinion, and the May 2021 VA psychiatric note. It should be noted that the Board has found that the April 2021 opinion is based upon an inaccurate factual premise because his service personnel records do not support a conclusion that he served under fire in Kosovo. The Board makes no further credibility findings at this juncture. The clinician should consider the appellant's reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant's reported symptoms. If there is any medical reason to accept or reject the proposition that the appellant's reported in-service symptoms represented the onset of any current psychiatric disability, this should be noted. Stated another way, do the appellant's reports align with how the currently diagnosed disability is known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? 4. Obtain a medical opinion from an appropriate clinician with regard to the nature and etiology of the appellant's hearing loss. The claims file must be made available to the clinician rendering the requested opinion. If the clinician determines that an examination is necessary, one should be scheduled. Following review of the claims file, the clinician should provide an opinion, with supporting rationale, as to whether it is at least as likely as not that hearing loss was incurred in service or are otherwise causally related to his active service or any incident therein, to include conceded military noise exposure. The examiner is informed that the July 2013 VA medical opinion appears to have mixed up the left and right ears when discussing the appellant's June 1982 enlistment examination. It is unclear to the Board at this time if the mistake was repeated when discussing other service audiograms, such as the December 1993 separation examination. The examiner is informed that the absence of in-service evidence of a hearing disability is not fatal to a claim of service connection for hearing loss. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Rather, evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). A complete rationale should be given for all opinions and conclusions expressed. The need for additional examination of the appellant is left to the discretion of the clinician rendering the opinion. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Behlen, 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.