Citation Nr: 21068829 Decision Date: 11/15/21 Archive Date: 11/15/21 DOCKET NO. 18-04 844 DATE: November 15, 2021 ORDER An effective date prior to July 15, 2013, for the grant of service connection for a right knee scar is denied. An effective date prior to July 15, 2013, for the award of a 20 percent rating for a lumbosacral strain with degenerative arthritis is denied. An effective date prior to July 15, 2013, for the award of a 10 percent rating for radiculopathy of the right lower extremity (RLE) is denied. A compensable rating for a right knee scar is denied. A rating in excess of 20 percent for a lumbosacral strain with degenerative arthritis is denied. A 20 percent rating, but no more, for RLE radiculopathy is granted, subject to the laws and regulations governing the payment of benefits. A rating in excess of 20 percent for residuals of a right tibia or fibula fracture is denied. Service connection for bilateral hearing loss is granted. Service connection for tinnitus is denied. Service connection for erectile dysfunction (ED) is denied. Service connection for posttraumatic stress disorder (PTSD) is denied. Service connection for obstructive OSA (OSA) is denied. Service connection for insomnia is denied. Service connection for a left knee disorder is denied. Service connection for a disorder manifested by small lymph nodes is denied. Special monthly compensation (SMC) based on the need for aid and attendance is denied. REMANDED An effective date prior to July 15, 2013, for the award of a 20 percent rating for residuals of a right tibia and fibula fracture. Service connection for a right hip disorder. Service connection for a right ankle disorder. Service connection for chronic obstructive pulmonary disease (COPD). Service connection for bronchitis. Service connection for bilateral lower extremity (BLE) edema. Service connection for the cause of the Veteran's death. A total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. FINDINGS OF FACT 1. The Veteran had active duty from April 1971 to September 1974. He died in June 2016 at the age of 62. 2. In February 2019, the Regional Office (RO) recognized the appellant, his widow, as an eligible substitute claimant in the appeal. 3. The claim of service connection for a right knee scar was received by VA on July 15, 2013; he was first diagnosed with a right knee scar on April 12, 2004. 4. There are no documents or communications dated prior to July 15, 2013, that constitute a claim of service connection for a right knee scar. 5. Symptoms of a lumbosacral strain and RLE radiculopathy were first diagnosed in March 2008 and December 2010; the Veteran's claim of increased ratings for service-connected lumbosacral strain and RLE radiculopathy was received on July 15, 2013. 6. It is not factually ascertainable that increases for a lumbosacral strain and RLE radiculopathy occurred prior to July 15, 2013. 7. For the entire period on appeal, a right knee scar was characterized by subjective complaints of increasing severity; objective findings include a single stable, non-painful scar with an approximate total affected area of 2.5 square centimeters (sq. cm.). 8. For the entire period on appeal, the lumbosacral strain was characterized by chronic mild to severe low back pain and back spasms; objective findings included forward flexion to 80 degrees, intervertebral disc syndrome (IVDS) with no incapacitating episodes over the 12 months prior to examination, and no ankylosis. 9. For the entire period on appeal, RLE radiculopathy was characterized by subjective complaints of numbness and a lack of feeling in the RLE and an inability to drive; objective findings included moderate constant pain, moderate numbness, and mild right-sided sciatica. 10. For the entire period on appeal, the residuals of a right tibial or fibular fracture were characterized by mild pain upon flare-ups, difficulty standing for certain periods of time without falling, and difficulty getting up and down; objective findings included forward flexion of the right knee to 140 degrees, extension of the right knee to 0 degrees, plantar flexion and dorsiflexion of the right ankle to 45 and 20 degrees, and no marked knee or ankle disability. 11. Bilateral hearing loss was continuous from the time of the Veteran's service to the date of his death. 12. At the time of the Veteran's death, diagnoses of tinnitus, ED, PTSD, OSA, and insomnia were not shown. 13. A left knee disorder was not diagnosed contemporaneous to the pendency of the claim. 14. A disorder manifested by small lymph nodes was not shown in service and were not causally or etiologically related to service. 15. At the time of his death, the Veteran was not in need of aid and attendance due to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to July 15, 2013, for the grant of service connection for a right knee scar have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.157, 3.321, 3.340, 3.400 (2021). 2. The criteria for an effective date prior to July 15, 2013, for the award of a 20 percent rating for a lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.157, 3.321, 3.340, 3.400 (2021). 3. The criteria for an effective date prior to July 15, 2013, for the award of a 10 percent rating for RLE radiculopathy have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.157, 3.321, 3.340, 3.400 (2021). 4. The criteria for a compensable rating for a right knee scar have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.20, 4.59, 4.118, Diagnostic Codes (DCs) 7801 7805 (2021). 5. The criteria for a rating in excess of 20 percent for a lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.20, 4.59, 4.71a, DCs 5237, 5243 (2021). 6. Resolving reasonable doubt in the appellant's favor, the criteria for a 20 percent rating, but no more, for RLE radiculopathy have been met for the entire period on appeal. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.20, 4.59, 4.124a, DC 8520 (2021). 7. The criteria for a rating in excess of 20 percent for residuals of a right tibial or fibular fracture have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.20, 4.59, 4.71a, DC 5262 (2020). 8. Bilateral hearing loss was incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.326, 3.385 (2021). 9. Tinnitus was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2021). 10. ED was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2021). 11. PTSD was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2021). 12. OSA was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2021). 13. Insomnia was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2021). 14. A left knee disorder was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2021). 15. A disorder manifested by small lymph nodes was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2021). 16. The criteria for SMC based on the need for aid and attendance have not been met. 38 U.S.C. §§ 1502, 1521 (2012); 38 C.F.R. §§ 3.350, 3.352 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As an initial matter, the Board remanded the claim of service connection for the cause of the Veteran's death on multiple occasions, most recently in June 2020, for additional development. The case has now been returned to the Board for further appellate action. Earlier Effective Date Turning to the relevant laws and regulations, unless specifically provided otherwise in the statute, the effective date of an award based on an original claim for compensation benefits shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. The effective date of an award of disability compensation shall be the date following separation from service or the date entitlement arose if the claim is received within one year of separation, otherwise the date of claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b); 38 C.F.R. § 3.400(b)(2). The effective date of an award based on a claim for increase of compensation "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application." 38 U.S.C. § 5110(a). The effective date for increased rating shall be the earliest date of which it is factually ascertainable that an increase in disability had occurred, if the claim is received within one year from such date; otherwise, the effective date for increased ratings shall be the date of receipt of claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). An effective date for increased rating may be assigned later than the date of receipt of the claim, if the evidence shows that the increase in disability actually occurred after the claim was filed, but never earlier than the date of receipt of the claim for increase. In general, "date of receipt" means the date on which a claim, information or evidence was received in VA. 38 C.F.R. § 3.1(r). A claim is a "formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit." 38 C.F.R. § 3.1(p). Right Knee Scar The Veteran was assigned an effective date of July 15, 2013, for the grant of service connection for a right knee scar, the date VA received the claim for the disorder. As he separated from service in September 1974, he is not entitled to an effective date within one year of his discharge from service. As to the date entitlement arose, the medical records reveal that a scar was noted on the Veteran's RLE in an April 12, 2004, treatment note. A subsequent January 2014 VA examination affirmed that the Veteran had a scar on his right knee. Therefore, April 12, 2004 is the date entitlement arose. As to the date of claim, the record establishes that the Veteran filed a claim for a right knee scar on July 15, 2013. While the RO granted service connection, he appealed the assigned rating and effective date in a December 2014 notice of disagreement (NOD). The July 2013 filing reasonably raised a claim of service connection for a right knee scar. Moreover, no other communication may be reasonably construed as a formal or informal claim for a right knee scar until the July 15, 2013 claim. This is the "date of claim." Effective dates are assigned based on the date of claim (July 15, 2013) or the date entitlement arose (April 12, 2004), whichever is later. As the July 15, 2013, claim is later than the date entitlement to a right knee scar arose, the effective date has been properly established as July 15, 2013. Accordingly, as the evidence is against the claim, entitlement to an effective date prior to July 15, 2013, for the grant of service connection for a right knee scar is not warranted and the benefit of the doubt doctrine is not for application. Lumbosacral Strain and RLE Radiculopathy The Veteran requested effective dates prior to July 15, 2013, for the assignment of 20 percent and 10 percent ratings for lumbosacral strain and RLE radiculopathy, respectively. To that end, in December 2014, he submitted an increased rating claim for the service-connected disorders that was received by VA on July 15, 2013. A July 2014 rating decision assigned 20 percent and 10 percent ratings for the lumbosacral strain and RLE radiculopathy, both effective July 15, 2013, the date of the increased rating claim. He timely appealed, asserting that the disorders were entitled to higher ratings and that he was not satisfied with the effective date of the 20 and 10 percent ratings. A review of the record reveals that a March 2008 imaging report diagnosed a degenerative lumbosacral disc and a subsequent August 2008 treatment note reported lower back pain. However, the March 2008 and August 2008 clinicians did not establish that the lumbosacral spine disorder met the criteria for a higher rating. Similarly, a December 2010 treatment note noted that the Veteran experienced numbness from the right calf down to the foot when sitting for too long; however, the December 2010 clinician also failed to establish that RLE radicular symptoms met the criteria for a higher rating. Based on the above, it is not factually ascertainable that the criteria for ratings in excess of 20 and 10 percent were met prior to July 15, 2013. Specifically, while medical treatment notes diagnosed a degenerative lumbosacral disc and lower back pain and noted symptoms of RLE radiculopathy, there were no medical findings indicating that the forward flexion of the lumbar spine was measured at 30 percent or less, that he had favorable ankylosis of the entire thoracolumbar spine, that he experienced incapacitating episodes as a result of IVDS, or that the severity of the RLE radiculopathy was moderate. Accordingly, the date of the July 15, 2013 claim was appropriately assigned as the effective date of the increased ratings and effective dates prior to July 15, 2013, for the grant of a 20 percent rating for a lumbosacral strain and a 10 percent rating for RLE radiculopathy are denied. Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Right Knee Scar The right knee scar was rated under DCs 7805 for other scars and other effects of scars. The Board will consider all relevant diagnostic codes. Under the relevant regulations, a compensable rating will be warranted when the evidence shows: A deep and nonlinear scar not of the head, face, or neck due to burns or other causes that has an area or areas of at least 6 square inches (sq. in.) (39 sq. cm.), but less than 12 sq. in. (77 sq. cm.) (10 percent under DC 7801); A superficial and nonlinear scar not of the head, face, or neck due to burns or other causes that has an area or areas of 144 sq. in. (929 sq. cm.) or greater (10 percent under DC 7802); or One or two scars that are unstable or painful (10 percent under 7804). In a January 2014 statement, the Veteran claimed that the right knee scar had worsened. In a VA examination later that month, an examiner diagnosed a scar that affected the RLE. The examiner found that the scar was not painful or unstable with frequent loss of covering of skin over the scar. The examiner further noted that the scar was not due to burns and determined that it was superficial and non-linear. The examiner measured the scar and approximated the total area a 2.5 sq. cm. and did not result in limitation of function or impact the Veteran's ability to work. Clinical records do not reflect findings inconsistent with the examination. Based on the above, a compensable rating is not warranted. In this regard, a January 2014 examiner diagnosed a scar that affected the Veteran's RLE; however, the scar was not painful or unstable and did not have a total area greater than 39 sq. cm. Accordingly, the medical evidence does not support a compensable rating for a right knee scar. Lumbosacral Strain with Degenerative Arthritis The lumbosacral strain was rated under DC 5237 for lumbosacral strains. The Board will consider all relevant diagnostic codes. Under the relevant regulations, an increased rating will be warranted when the evidence shows: Forward flexion of the thoracolumbar spine at 30 degrees or less (40 percent under DC 5237); Favorable ankylosis of the entire thoracolumbar spine (40 percent under DC 5237); or IVDS with incapacitating episodes having a duration of at least 4 weeks but less than 6 weeks over the 12 months prior to examination (40 percent under DC 5243). In medical treatment notes between June 2013 and January 2014 contemporaneous with the claim, the Veteran described experiencing chronic low back pain that made him limp and additional back spasms. In a subsequent January 2014 statement and multiple January 2014 VA examinations, he asserted that low back disability had worsened and reported having daily mild to severe mechanical low back pain that kept him awake. A January 2014 examiner measured the forward flexion of the lumbar spine to 80 degrees. The examiner further found that the Veteran had tenderness to palpation of the lumbar spinal processes, bilateral lumbosacral myofascia, and muscle spasms resulting in abnormal gait or spinal contour; however, ankylosis was not shown. Further, IVDS was noted, he did not have incapacitating episodes due to IVDS over the 12 months prior to examination. The examiner diagnosed lumbar degenerative disease, mild right-sided sciatica, and lumbar osteoarthritis. In March 2014 buddy statements, friends and family indicated that the Veteran's back pain was constant and had grown very intense. However, in subsequent medical treatment notes, he reported that back pain was intermittent. An MRI conducted in September 2015 and reported the following month observed mild degenerative changes in the lumbar spine, but neither the medical treatment notes nor the MRI assessed the range of motion of the lumbar spine or determined whether he had ankylosis and IVDS. In July 2017 and May 2019 statements, the appellant explained that the Veteran was in severe pain prior to his death. She noted that he was issued a walker due to excessive falls and a neck brace to take pressure off the base of the spine. She asserted that, in part because of the severe back pain, the Veteran became unable to drive. She recalled that nothing seemed to stop the pain. Based on the above, a rating in excess of 20 percent is not warranted. In this regard, the Veteran, his friend, and the appellant described how he experienced chronic mild to severe low back pain with back spasms prior to his death; however, the January 2014 examiner found that the forward flexion of the lumbar spine was measured to 80 degrees, that he did not demonstrate ankylosis. Further, while IVDS was shown, the examiner reported that it did not result in any incapacitating episodes. Accordingly, the medical evidence does not support a rating in excess of 20 percent. RLE Radiculopathy RLE radiculopathy was rated under DC 8520 for paralysis of the sciatic nerve. The Board will consider all relevant diagnostic codes. Under the relevant regulations, a higher rating will be warranted when the objective medical evidence shows moderate incomplete paralysis of the sciatic nerve (20% under DC 8520). The words such as "severe," moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. In a January 2014 lay statement and VA examination, the Veteran reported experiencing worsening symptoms of RLE radiculopathy, including constant pain in the right buttock and right posterior thigh, as well as numbness in the right great toe. Upon examination, the examiner found moderate constant pain and numbness and no intermittent pain, paresthesias, or dysesthesias. The examiner determined that the symptoms affected the sciatic nerve and found that it was mild. In a June 2014 medical treatment note, the Veteran reported that the right foot was constantly numb and sometimes painful. In May 2016, he further reported numbness below the right knee that came and went but said that the RLE was not painful. However, in both cases, clinicians did not assess the then-current severity of the RLE radiculopathy. In July 2017 and May 2019 statements, the appellant reported that prior to his death, the Veteran was unable to drive as a result of the numbness in the legs. She explained that at the time, the legs were numb from the knees down and he had no feeling in the extremities. She recounted that he could not drive a vehicle because, as a result of the numbness, he never knew when his foot would accidentally press down on a car's accelerator without realizing it. Based on the above, a rating of 20 percent, but no more, is warranted for RLE radiculopathy. In this regard, the Veteran reported worsening numbness and pain and the medical evidence, at worst, showed moderate constant pain and numbness. Moderate constant pain is not automatically indicative of moderate incomplete paralysis under DC 8520. To this end, the January 2014 examiner characterized the symptoms as mild incomplete paralysis of the sciatic nerve. However, as noted above, the use of terminology by medical professionals such as "mild" and "moderate" does not automatically determine the appropriate level of disability for the Veteran's RLE radiculopathy. Rather, the appellant's lay statements establish that prior to his death, the Veteran had no feeling in the lower extremities and that the radicular symptoms were severe enough to prevent him from driving. Accordingly, resolving reasonable doubt in her favor, a 20 percent for RLE radiculopathy is warranted, and the appeal is granted to this extent. Nonetheless, a 40 percent rating is not warranted. To this end, the Veteran reported in May 2016 that he had numbness below the right knee that "[came] and [went]" and denied pain in the RLE. The medical and lay evidence does not otherwise establish that he had "moderately severe" symptoms of RLE radiculopathy that would justify a 40 percent rating. Therefore, a rating in excess of 20 percent is not warranted. Residuals of a Right Tibia or Fibula Fracture The residuals of a right tibia or fibula fracture were rated under DC 5262 for impairments of the tibia and fibula. The Board will consider all relevant diagnostic codes. Under the relevant regulations, an increased rating will be warranted when the evidence shows malunion of the tibia and fibula with a marked knee or ankle disability. The Board notes that the criteria for rating disabilities of the musculoskeletal system, to include impairments of the tibia or fibula, were amended, effect February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). Generally, if a law or regulation changes over the course of a claim or appeal, the Board will consider both the pre-amended and current rating criteria and apply the more favorable version. However, the Veteran died before the changes were implemented; as such, only the pre-amended criteria is applicable, and the Board will proceed accordingly. At the time of the Veteran's death, the Rating Schedule did not provide any information as to what manifestations constituted "moderate" or "marked" knee or ankle disabilities; however, VBA's M21-1 Live Manual stated that "moderate" limitation of motion was present when there was less than 15 degrees dorsiflexion or less than 30 degrees of plantar flexion and that "marked" limitation of motion was present when there was less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. See M21-1, Live Manual, Part III, Subpart iv, Chapter 4, Section A, Topic 3, Block k. In a general-purpose dictionary, "moderate" is defined as "limited in scope or effect . . . [or] not seriously or permanently disabling or incapacitating," while "marked" is defined as "distinctive, strongly pronounced, or noticeable." Webster's Third International Dictionary (1986); see Terry v. Principi, 340 F.3d 1378 (Fed. Cir. 2003). Turning to the evidence, the Veteran was diagnosed with an open proximal right tibia or fibula fracture in a January 2014 VA examination. While he denied daily tibia or fibula pain, he said that he experienced mild pain in the right tibia and fibula during flare-ups on exposure to cold temperatures. Upon examination, flexion of the right knee was measured to 140 degrees. He reported having a leg length discrepancy but said that he did not have tenderness or pain to palpation for the joint lines or soft tissues of the knees. In an additional January 2014 VA examination, the Veteran was diagnosed with osteopenia of the right ankle. He denied daily right ankle pain but said that upon flare-ups, he experienced mild bilateral mechanical ankle pain that was worse in the left ankle and relieved by sitting with the legs elevated for an hour. Upon examination, plantar flexion and dorsiflexion were measured to 45 and 20 degrees, respectively. The examiner found that the Veteran did not experience localized tenderness or pain on palpation of the joints or soft tissues of either ankle, and noted that the disorder did not impact his ability to work. In March 2014 statements, the appellant and the Veteran's friend reported that he had problems with the legs and hips, had trouble getting up and down, and was not able to stand for certain periods of time without falling. Subsequently, an October 2015 treatment note observed that he had 0-trace reflexes in the bilateral ankle. He further reported numbness below the right knee that came and went in a May 2016 treatment note. Based on the above, a 30 percent rating for residuals of a tibial or fibular fracture is not warranted. In this regard, the evidence establishes that the Veteran experienced mild pain in the tibia, fibula, and ankle. Furthermore, friends noted that he had difficulty getting up and down and standing for periods of time without falling. However, he indicated that he did not have daily tibia, fibula, or ankle pain, noted that he only experienced pain upon flare-ups of the knee and ankle disorders, and said that the pain resolved when he was in warmer temperatures or spent an hour with the legs elevated. Therefore, a marked ankle or knee disability has not been established. As such, the medical evidence does not support a 30 percent rating for residuals of a right tibial or fibular fracture. Consideration has been given to assigning staged ratings with respect to the disabilities discussed above. However, at no time during the periods in questions have the disabilities warranted higher schedular ratings than those assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). Service Connection Claims Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. § 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. Bilateral Hearing Loss In addition to the above, impaired hearing, for VA purposes, will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels (dB) or greater, the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 dB or greater, or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Hearing loss is recognized by VA as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. §§ 3.303(b), 3.307, and 3.309 apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015). Turning to the evidence, at the time of his death the Veteran had a then-current diagnosis of bilateral sensorineural hearing loss. Specifically, a January 2014 VA examination diagnosed bilateral sensorineural hearing loss. Accordingly, a disorder current at the time of the Veteran's death has been shown and the first element of service connection has been met. A review of the evidence reveals that the Veteran was exposed to loud noise (acoustic trauma) while in service. In this regard, he reported in a January 2014 VA examination that his military duties included service as a helicopter crew chief and master door gunner. In a subsequent May 2019 statement, the appellant recounted that he flew on helicopters and performed duties with 50-caliber machine guns, and that he had hearing loss and ear problems. The DD-214 and personnel records affirm that he had service as a helicopter mechanic. He and the appellant asserted that he had noise exposure from helicopters and machine gun fire. Moreover, the January 2014 examiner indicated that the Veteran's military duties included a high probability of noise exposure. Based on this evidence, in-service noise exposure is established. Next, as to continuity, the appellant reported in a May 2019 statement that over the course of his life, the Veteran had hearing loss and ear problems as a result of flying on helicopters and performing duties with 50-caliber machine guns while in service. Lay witnesses are competent to assert that a veteran has experienced the symptoms of hearing loss continuously since active service. Therefore, resolving reasonable doubt in her favor, her credible and competent lay statement establishes continuity of symptomatology. While there is an absence of complaints of or treatment for hearing loss for many years after separation from service, the Board has resolved reasonable doubt in the appellant's favor and finds that at the time of his death, the Veteran had symptoms of hearing loss that had been continuous since separation from service. As such, the requirements of presumptive service connection under 38 C.F.R. § 3.303(b) are met. Although a January 2014 examiner opined that the Veteran's hearing loss was less likely than not caused by or related to service, the Board does not need to reach the weight assignable to the VA opinion because service connection is granted on a presumptive basis under 38 C.F.R. § 3.303(b) for the "chronic" disease of bilateral hearing loss based on a finding of "continuous" symptoms since service. In sum, there is evidence of acoustic trauma in-service and continuous symptoms of bilateral hearing loss between separation and the date of his death; therefore, bilateral hearing loss is presumed to have been incurred in service and the appeal is granted to this extent. Because the Board is granting service connection on a presumptive basis based on continuous symptoms of bilateral hearing loss since separation, all other theories of service connection are rendered moot. Tinnitus, ED, PTSD, OSA, and Insomnia In addition to the above, for a disability to be service connected, it must be present at the time a claim for VA disability compensation is filed or during or contemporary to the pendency of the appeal. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The record does not show that the Veteran had confirmed diagnoses of tinnitus, ED, PTSD, OSA, or insomnia at any time during or contemporary to the pendency of the appeal. To that end, he and the appellant asserted in multiple statements prior to and after the date of his death that he had ear trouble, PTSD, OSA and insomnia. They observed in multiple January 2014 VA examinations and additional lay statements that he had complaints of ear popping and dizziness, mental confusion, depression, sadness, and trouble sleeping. However, lay witnesses are not competent to diagnose tinnitus, ED, and PTSD, or to determine whether the sleeping difficulties were indicative of OSA and insomnia. Ultimately, the medical evidence does not reflect diagnoses of tinnitus, ED, PTSD, OSA, or insomnia at any time during or contemporary to the pendency of the claim. Of note, the Veteran asserted in the July 2013 claim that OSA was due to PTSD. However, without a current diagnosis, service connection is not warranted under any theory of entitlement. As noted above, service connection may only be granted for a current disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As there were no confirmed diagnoses that were current at the time of the Veteran's death or at any other time during the pendency of the appeal, secondary service connection for OSA is not warranted and service connection is not otherwise warranted for tinnitus, ED, PTSD, OSA or insomnia. Left Knee Disorder As previously discussed, service connection may only be granted for a current disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The "current disability" requirement may be satisfied if the record contains a recent diagnosis of disability prior to filing a claim for benefits based on that disability. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). In a May 2003 treatment note, the Veteran reported noticing pain behind the left knee 7 days prior to examination. He said that at the time of examination, the pain was in the calf with swelling; however, he did not file a claim until July 2013, a decade after his report of left knee symptoms. Accordingly, the May 2003 symptoms are not contemporary to the Veteran's July 2013 claim and do not constitute a current diagnosis for purposes of service connection. The medical evidence does not otherwise reflect a diagnosis of a left knee disorder at any time during or contemporaneous to the pendency of the claim. To this end, the Veteran underwent a VA examination in January 2014 prior to his death. The examiner found a fracture of the right tibia and fibula and noted a leg length discrepancy between the left and right legs but did not diagnose a left knee disorder. In a subsequent March 2014 buddy statement, a friend indicated that the Veteran experienced the loss of reflexes in both of the knees. Lay witnesses are competent to report subjective symptoms and describe their observations because this requires only personal knowledge as it comes to them through their senses. However, they are not competent to make medical findings or diagnose a left knee disorder. Accordingly, the March 2014 buddy statement is assigned lesser weight. Service connection may only be granted for disabilities that were present at the time of the Veteran's death. As there was no confirmed diagnosis of a left knee disorder that was current at the time of his death or at any other time during the pendency of the appeal, service connection for a left knee disorder is not warranted and the appeal is denied to this extent. Small Lymph Nodes As an initial matter, small lymph nodes are not a current diagnosis under 38 C.F.R. § 3.309(a); therefore, presumptive service connection on the basis of continuity of symptomatology is not for application. Furthermore, neither the appellant nor the Veteran asserted that the lymph nodes were proximately related to a service-connected disability; as such, secondary service connection will not be addressed. However, direct service connection will be discussed. Turning to the evidence, the Veteran was diagnosed with a lymph node disorder at the time of his death. To that end, an August 2013 imaging report diagnosed nonspecific postinflammatory lymph nodes in the mediastinum and both axillary regions. Accordingly, a lymph node disorder current at the time of the Veteran's death has been shown and the first element of service connection has been met. As to in-service incurrence, a review of the STRs reveals that the Veteran's chest, lungs, and heart were found to be clinically normal in April 1971 and August 1972 medical examinations. He additionally reported in an April 1974 Report of Medical History that he did not then-presently or previously have pain or pressure in the chest, shortness of breath, asthma, a chronic cough, palpitations or pounding heart, heart trouble, or high or low blood pressure. The STRs are otherwise silent for complaints, diagnoses, or treatment for lymph nodes or for symptoms thereof. Accordingly, the second element of service connection an in-service incurrence has not been met. In light of the above, the medical evidence does not support the claim of service connection for small lymph nodes. The Board has considered the lay articles submitted by the appellant and the Veteran regarding the symptoms caused by Ibuprofen and the service history of Marine Medium Tiltrotor Squadron 163; however, the medical article does not address the Veteran's specific case or establish that the claimed disorders were related to ibuprofen usage. Additionally, while the service history article describes the unit in which the Veteran served, the excerpt does not address the years during which he was in active service. The Board has also considered the lay statements submitted by the Veteran, his friend, and the appellant regarding the etiology and current severity of the disabilities addressed above. Lay witnesses are competent to report symptoms and describe their observations because this requires only personal knowledge as it comes to them through their senses. However, they are not competent to offer opinions as to the etiology or specific level of disability according to the appropriate diagnostic code of any current disorder due to the medical complexity of the matters involved. Such competent evidence has been provided by the medical personnel who have examined the Veteran prior to his death during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the VA examinations and medical treatment notes) directly address the criteria under which the disabilities are evaluated. As the clinicians have the requisite medical experience to render medical opinions regarding the degree of impairment caused by the disabilities and had sufficient facts and data on which to base the conclusions, the Board attaches greater probative weight to the clinical findings than to the lay statements that have been submitted. Based on the above, service connection for hearing loss and a rating of 20 percent, but no more, for RLE radiculopathy are granted and the appeals are otherwise denied. SMC for Aid and Attendance SMC may be granted based on the need for aid and attendance if a veteran, as a result of service-connected disabilities, has suffered the anatomical loss or loss of use of both feet or one hand and one foot, or is blind in both eyes, or is permanently bedridden, or is so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1141(l); 38 C.F.R. § 3.350(b). Under 38 C.F.R. § 3.352(a), the following criteria are to be considered for determining whether a claimant is in need of regular aid and attendance: (1) an inability to dress himself or herself or keep himself or herself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliance which, by reason of the particular disability, cannot be done without aid (not to include the adjustment of appliances which normal persons would be unable to adjust without aid such as supports, belts, or lacing at the back); (3) the inability of the claimant to feed himself or herself through the loss of coordination or through extreme weakness; (4) the inability to attend to the wants of nature; or (5) a physical or mental incapacity that requires care and assistance on a regular basis to protect the claimant from the hazards or dangers incident to his or her daily environment. "Bedridden," which is a proper basis for the determination, is defined as that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that a claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. 38 C.F.R. §§ 3.350(b)(4), 3.352(a). Turning to the medical evidence, the evidence is in equipoise as to whether the Veteran was able to dress himself or keep himself clean at the time of his death. Specifically, on the one hand, a private clinician determined in an August 2013 Disability Benefits Questionnaire (DBQ) that the Veteran required assistance with dressing, bathing, and personal hygiene. This evidence weighs in favor of the claim. Additionally, a friend reported in a March 2014 statement that the Veteran was no longer capable of functioning in the outside world and that someone had to help him with personal hygiene. The appellant elaborated in an additional March 2014 statement that he had to be reminded to perform activities of daily living, including showering, ordering medications, and preparing medications. This evidence also weighs in favor of the appeal. On the other hand, a January 2014 VA examination found that the Veteran's ability to maintain his personal hygiene and perform other basic activities of daily living appeared intact. This evidence weighs against the claim. Nevertheless, there is evidence both establishing and against the Veteran's ability to dress himself and keep himself clean. Accordingly, resolving reasonable doubt in the appellant's favor, the record establishes that he was unable to dress or keep himself ordinarily clean or presentable at the time of his death. Next, the Veteran required assistance in preparing meals at the time of his death. To this end, an August 2013 DBQ found that he was unable to feed himself and required assistance and encouragement in order to eat. In multiple subsequent March 2014 buddy statements, the appellant and a friend reinforced that he needed to have meals prepared for him. The evidence establishes that he required assistance in preparing meals and encouragement to eat. However, the record does not indicate that any inability to feed himself was the result of loss of coordination of the upper extremities or extreme weakness. As to prosthetics and orthopedics, a clinician reported in an August 2013 DBQ that the Veteran required an assistive device due to balance problems. However, a subsequent January 2014 VA examination found that he did not use an orthopedic or prosthetic device. Furthermore, the August 2013 DBQ did not specify that he was unable to adjust his assistive device without aid as a result of the disabilities. With regard to protection from hazards and dangers, the Veteran reported in multiple January 2014 VA examinations that he had no dizziness and occasional memory loss and that right foot twitching and jumping intermittently interfered with the ability to drive. He said that the twitching and jumping made him feel unsafe to drive and that he required his wife to drive him to appointments and run errands. In subsequent March 2014 and May 2019 lay statements, the appellant and a friend reported that he was "not driving material," and was unable to go anywhere. She explained that the Veteran did not drive due to an inability to control the pedals, noting that he was worried that his disabilities would cause the right foot to drop down on the accelerator. She highlighted that she did all of the driving for the VA appointments and said that he was basically confined to home as a result. However, the January 2014 VA examiner found that the Veteran was able to walk without assistance for up to 0.5 miles. The examiner noted that he had twitching and jumping in the right foot that interfered with the ability to drive but found that no other body parts or system impairments- including lower extremity disorders- affected the ability to protect himself from the daily environment. Ultimately, the medical evidence does not establish that the Veteran required regular care and assistance in order to protect himself from the hazards or dangers incident to the daily environment. Based on the above, SMC based on a need for aid and attendance is not warranted. In this regard, the medical treatment notes and VA examinations reflect that at the time of his death, the Veteran required assistance with dressing, bathing, and personal hygiene and had to be reminded to perform activities of daily living. The record further establishes that he required assistance in preparing meals, encouragement to eat, and an assistive device in order to address balance problems. The evidence finally reveals that the disabilities prevented him from driving and caused him to require assistance in order to get to appointments or run errands. However, the evidence of record does not show that the Veteran's impaired ability to prepare and eat meals was due to extreme weakness or loss of coordination of the upper extremities. Likewise, the record does not show that he had to frequently adjust his assistive device and was unable to do so without assistance. Finally, while the evidence reflects an inability to drive, it does not show that he required assistance in order to protect himself from the hazards and dangers of his daily environment. As such, neither the medical nor lay evidence supports entitlement to SMC based on a need for aid and attendance and there is no doubt to be otherwise resolved. The Board has considered the statements submitted by the Veteran, the appellant, and a friend regarding the need for aid and attendance throughout the entire period on appeal. While lay witnesses are competent to report symptoms because this requires only personal knowledge as it comes to them through their senses, they are not competent to identify a specific level of symptomatology sufficient to satisfy the requirements of 38 C.F.R. §§ 3.350 and 3.352. Such competent evidence concerning the nature and etiology of the Veteran's need for aid and attendance have been provided by the medical personnel who examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and clinical records) directly address the criteria under which the need for aid and attendance is evaluated. Moreover, as the examiners have the requisite medical expertise to render medical opinions regarding the degree of impairment caused by the service-connected disabilities and had sufficient facts and data on which to base the conclusions, the Board affords the medical opinions great probative value. As such, these records are more probative than the subjective evidence of complaints of increased symptomatology submitted by the Veteran, his friend, and the Appellant. Finally, the appellant has not raised any other issues, nor have any other issues been reasonably raised by the record for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Effective Date for Grant of 20 Percent Rating for Right Tibia and Fibula Fracture. A review of the record shows that in December 2014, the Veteran submitted an NOD with a July 2014 rating decision continuing a claim for an increased rating for residuals of a right tibia and fibula fracture. He indicated disagreement with both the rating and the effective date that were assigned. In May 2019, a statement of the case (SOC) was issued; however, it did not address the effective date claim. Where an NOD has been filed with regard to an issue and a SOC has not been issued, the appropriate Board action is to remand the issue for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, remand is necessary for the issuance of a SOC on the issue. Service Connection for Right Hip and Right Ankle Disorders, Turning to service connection for right hip and right ankle disorders, in January 2014, the Veteran was afforded examinations for the two disabilities. The examiner opined that it was less likely than not that the right hip and right ankle disorders were proximately due to a service-connected condition, finding instead that it was more likely than not that the right hip and right ankles were the products of chronic degenerative changes associated with aging and bilateral chronic venous insufficiency, respectively. However, a review of the service treatment records (STRs) reveals that the Veteran complained of abrasions of the right hip and right hip pain in September 1972 and January 1974, and pain in the right ankle diagnosed as peroneal tendonitis in June 1973. The January 2014 examiner did not assess whether a relationship existed between the then-current diagnoses and the in-service right hip and right ankle disorders. As such, further development is required in order to determine the nature and etiology of the Veteran's right hip and right ankle disorders. Service Connection for COPD, Bronchitis and BLE Edema. As to COPD, bronchitis, and BLE edema, in July 2013, the Veteran submitted a claim for COPD and asserted that the disorder was the product of asbestos exposure. In a subsequent October 2013 statement, he reported increased edema to the bilateral lower extremities as well as symptoms of bronchitis including shortness of breath and weakness. He asserted that the increased edema and bronchial symptoms "all progressed from high exposure to asbestos on [the] USS Tripoli." In additional July 2017, April 2020, and September 2020 statements offered after the Veteran's death, the appellant explained that he flew in helicopters during service and flew casualties and injured servicemembers to the USS Tripoli. She said that he stayed aboard the ship in between operations and was exposed to asbestos as a result. Next, in April 2020, VA received a Radiation Risk Activity Information Sheet in which the Appellant asserted that the Veteran's disorders were the result of exposure to ionizing radiation when using infrared night vision and having contact with electromagnetic fields. In an August 2020, the examiner offered that COPD was at least as likely as not incurred in, caused by, or otherwise related to service, explaining that the respiratory disorder was the result of his smoking history and that a multi-year history of smoking was the result of the stresses of service. The examiner further offered that COPD was at least as likely as not related to chronic bronchitis. However, under VA regulations, where a claim is filed after June 9, 1998, in-service smoking history cannot be the basis for a nexus between a veteran's active service and claimed disorders. 38 C.F.R. § 3.300. Further, the examiner did not offer an opinion as to whether the Veteran's BLE edema was incurred in, aggravated by, or caused by active service. In addition, the examiner did not address whether the three disorders were etiologically related to any in-service exposure to asbestos and ionizing radiation. As such, further development is required to determine the nature and etiology of COPD, bronchitis, and BLE edema. Service Connection for the Cause of the Veteran's Death. With regard to the claim of service connection for the cause of the Veteran's death, the Veteran's death certificate shows that his immediate cause of his death was COPD. As such, the claim is inextricably intertwined with the pending claim of service connection for COPD discussed above, and as such, regrettably, action on the claim will also be remanded. TDIU. Next, additional development is required before the claim of entitlement to a TDIU on an extraschedular basis may be decided. Specifically, at the time of his death, the Veteran was service connected for residuals of a right tibia and fibula fracture, a lumbosacral strain, and RLE radiculopathy at 20 percent each. He additionally received a noncompensable rating for a right knee scar. The combined rating was 50 percent. As such, at the time of his death he did not meet the minimum schedular criteria for entitlement to a TDIU. Accordingly, TDIU may only be granted on an extraschedular basis. Although entitlement to extraschedular TDIU is determined in the first instance by the Director of Compensation Service, the RO and Board are tasked with making the threshold determination that referral to the Director for extraschedular consideration is appropriate. That threshold determination must be supported with "a full statement as to the veteran's service-connected disabilities, employment history, educational and vocational attainment and all other factors having a bearing on the issue." 38 C.F.R. § 4.16(b). Of note, "substantially gainful employment" is not currently defined in VA regulations. However, the Court defined the term as having two components: one economic and one non-economic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the following: the veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. In other words, the non-economic component requires consideration of a veteran's ability to secure or follow that type of employment. Ray v. Wilkie, 31 Vet. App. 58 (2019). Turning to the evidence, the Veteran, his friend, and the appellant asserted in multiple lay statements that he worked at the United States Postal Service (USPS) for 23 years. In an August 2013 statement, the appellant noted that every time the Veteran was left alone, he got injured, lost, or confused. Subsequently in March 2014, she explained that he was unable to walk or stand for any length of time, had no muscle strength with which to lift, had difficulty bending and stooping, and was "basically confined to [his] home" as a result of the disabilities. The evidence is sufficient to warrant a remand for extraschedular consideration. The matters are REMANDED for the following actions: 1. Identify and obtain any pertinent, outstanding VA and private treatment records not already of record and associate them with the claims file. 2. Issue a statement of the case on the issue of an effective date prior to July 15, 2013, for the grant of a 20 percent rating for residuals of a right tibia and fibula fracture. Inform the appellant of the requirements to perfect an appeal. If she perfects an appeal, return the issue to the Board. 3. Direct the claims file to a clinician for opinions as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's right hip and right ankle disorders were etiologically related to service. In forming the opinions, the clinician must address the September 1972 and January 1974 STRs describing and diagnosing a right hip abrasion and right hip pain, and the June 1973 STR describing and diagnosing right ankle pain and peroneal tendonitis. 4. Direct the claims file to a clinician for opinions as to the nature and etiology of COPD, bronchitis, and BLE edema. The clinician is asked to opine as to whether it is at least as likely as not (a 50 percent probability or greater) that: (a.) COPD was etiologically related to service, to specifically include in-service exposure to asbestos and ionizing radiation; (b.) bronchitis was etiologically related to service, to specifically include in-service exposure to asbestos and ionizing radiation; and (c.) BLE edema was etiologically related to service, to specifically include in-service exposure to asbestos and ionizing radiation. The clinician is advised that under 38 C.F.R. § 3.300, an in-service history of smoking cannot constitute the basis for a nexus between the claimed disorders and the Veteran's active service. The clinician is instructed to specifically address the Veteran's October 2013 statement and the appellant's July 2017, April 2020, and September 2020 statements describing his history of in-service asbestos exposure. The rationale for all opinions must be provided. 5. Refer the case to the Director of Compensation Service for consideration of whether entitlement to an extraschedular TDIU is warranted pursuant to 38 C.F.R. § 4.16(b). Thereafter, implement the determination of the Director, if so warranted. L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Spigelman, Associate 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.