Citation Nr: 21070995 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 16-45 315 DATE: November 29, 2021 ORDER Entitlement to service connection for an acquired psychiatric disability, claimed as posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for obstructive sleep apnea is denied. Entitlement to service connection for a migraine headache disorder is denied. Entitlement to service connection for diabetes mellitus, type II, is denied. Entitlement to service connection for right upper extremity peripheral neuropathy, diagnosed as diabetic neuropathy, is denied. Entitlement to service connection for left upper extremity peripheral neuropathy, diagnosed as diabetic neuropathy, is denied. Entitlement to service connection for right lower extremity peripheral neuropathy, diagnosed as diabetic neuropathy, is denied. Entitlement to service connection for left lower extremity peripheral neuropathy, diagnosed as diabetic neuropathy, is denied. Entitlement to an effective date prior to December 27, 2011, for the grant of service connection for tinnitus is denied. Entitlement to an effective date prior to December 27, 2011 for the grant of service connection for bilateral hearing loss is denied. Entitlement to an initial rating in excess of 10 percent for service-connected tinnitus is denied. REMANDED Entitlement to an initial rating in excess of 10 percent for service-connected bilateral hearing loss is remanded. FINDINGS OF FACT 1. The evidence of record does not support a finding that the Veteran served in the Republic of Vietnam, and his reported stressor cannot be verified; he did not suffer an in-service incident, illness or injury to which any presently diagnosed acquired psychiatric disability may be etiologically linked; his present psychiatric symptoms did not have onset during service and have not continued from the time of service; there is no medical evidence or opinion linking his present psychiatric symptoms to any confirmed incident of active service. 2. The Veteran did not suffer any incident, illness or injury to which his present hypertension may be etiologically linked; his hypertension did not manifest until many years following service and there is no medical nexus to service. 3. The Veteran did not suffer any incident, illness or injury to which his present sleep apnea may be etiologically linked; his sleep apnea did not manifest until many years following service and there is no medical nexus to service. 4. The Veteran did not suffer any incident, illness or injury to which his present migraine headaches may be etiologically linked; his migraine headaches did not manifest until many years following service and there is no medical nexus to service. 5. The Veteran was not exposed to an herbicide agent during active duty service; he did not suffer any in-service incident, illness or injury to which his present diabetes mellitus, type II, may be etiologically linked; his present diabetes mellitus did not manifest to a compensable degree during active service or within one year of separation from service; no medical nexus to service is established. 6. The Veteran was not exposed to an herbicide agent during active duty service; he did not suffer any in-service incident, illness or injury to which his present right upper extremity diabetic neuropathy, may be etiologically linked; his present right upper extremity diabetic neuropathy did not manifest to a compensable degree during active service or within one year of separation from service; no medical nexus to service is established; the Veteran's right upper extremity diabetic neuropathy is directly caused by his non-service-connected diabetes mellitus. 7. The Veteran was not exposed to an herbicide agent during active duty service; he did not suffer any in-service incident, illness or injury to which his present left upper extremity diabetic neuropathy, may be etiologically linked; his present left upper extremity diabetic neuropathy did not manifest to a compensable degree during active service or within one year of separation from service; no medical nexus to service is established; the Veteran's left upper extremity diabetic neuropathy is directly caused by his non-service-connected diabetes mellitus. 8. The Veteran was not exposed to an herbicide agent during active duty service; he did not suffer any in-service incident, illness or injury to which his present right lower extremity diabetic neuropathy, may be etiologically linked; his present right lower extremity diabetic neuropathy did not manifest to a compensable degree during active service or within one year of separation from service; no medical nexus to service is established; the Veteran's right lower extremity diabetic neuropathy is directly caused by his non-service-connected diabetes mellitus. 9. The Veteran was not exposed to an herbicide agent during active duty service; he did not suffer any in-service incident, illness or injury to which his present left lower extremity diabetic neuropathy, may be etiologically linked; his present left lower extremity diabetic neuropathy did not manifest to a compensable degree during active service or within one year of separation from service; no medical nexus to service is established; the Veteran's left lower extremity diabetic neuropathy is directly caused by his non-service-connected diabetes mellitus. 10. The Veteran filed a claim for service connection for tinnitus on December 27, 2011; prior to that date there is no evidence of any intent to claim service connection for that disability. 11. The Veteran filed a claim for service connection for bilateral hearing loss on December 27, 2011; prior to that date there is no evidence of any intent to claim service connection for that disability. 12. The Veteran is in receipt of the maximum allowable schedular rating for tinnitus; his tinnitus is manifested by ringing in the ears without any additional complications or symptoms; his symptoms are anticipated by the diagnostic rating criteria and do not cause economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disability, to include PTSD, are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. The criteria for service connection for migraine headaches are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 5. The criteria for service connection for diabetes mellitus, type II, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for service connection for right upper extremity diabetic neuropathy are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for service connection for left upper extremity diabetic neuropathy are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria for service connection for right lower extremity diabetic neuropathy are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 9. The criteria for service connection for left lower extremity diabetic neuropathy are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 10. The criteria for an effective date prior to December 27, 2011, for the grant of service connection for tinnitus have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 11. The criteria for an effective date prior to December 27, 2011, for the grant of service connection for bilateral hearing loss have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 12. The criteria for a rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.87, Diagnostic Code (DC) 6260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1970 to May 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2013, October 2013, and May 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran initially requested a videoconference hearing before a Veterans Law Judge via VA Form 9 (Appeal to the Board of Veterans' Appeals). In July 2021, the Veteran, via his attorney, submitted a written statement expressing his desire to withdraw his hearing request and proceed with a decision based on the evidence of record. As such, his hearing request is withdrawn. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, certain chronic diseases, including diabetes and other organic disabilities of the nervous system such as neuropathy, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Regardless of whether or not a disability is listed as "chronic" for presumptive purposes, a continuity of symptoms from the time of service is a factor to consider in assessing any service connection claim. Further, if a veteran was exposed to a herbicide agent during active military, naval, or air service in Vietnam, then certain diseases, such as type II diabetes, shall be service connected even though there is no record of such disease during service. For the purposes of this section, the term "herbicide agent" means a chemical in a herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e), 3.313. If a disability is not listed a presumptive of herbicide exposure, service connection may still be established secondary to herbicide exposure if the evidence suggests a medical nexus between the disability and the herbicide exposure. This is generally established under the principles of direct service connection, as described above. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. A disability may also be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. 1. Entitlement to service connection for an acquired psychiatric disability, claimed as posttraumatic stress disorder (PTSD) The Veteran seeks service connection for PTSD, which he asserts is related to combat stressors he encountered while serving in the Republic of Vietnam. The Board finds that the claim must be denied. Initially, the Board recognizes that a claim for service connection for PTSD includes a claim for any psychiatric disability which may account for the Veteran's reported symptoms. Clemons v. Shinseki, 23 Vet. App. 1 (2009). As such, the Board has broadened the claim to include any acquired psychiatric disability, to include PTSD, which may account for the Veteran's symptoms. Unlike other psychiatric disabilities, PTSD has specific diagnostic requirements for a grant of service connection. In order to establish entitlement to service connection for PTSD, specifically, the Veteran must show: (1) a diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a) (referencing the standards of the DSM-5); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). In this case, however, the outcome of the appeal does not turn on the nature of the Veteran's current psychiatric diagnosis. Instead, it turns on the inability to corroborate the Veteran's account of his in-service experiences such that service connection can be granted under either 38 C.F.R. § 3.303 or 38 C.F.R. § 3.304(f). As will be explained below, the information included in the Veteran's service treatment and personnel records and inconsistencies in the Veteran's own statements regarding his in-service experiences weigh against finding that the in-service events he has described occurred. Turning to the evidence of record, in May 2013, the RO sent a letter to the Veteran requesting specific evidence of his reported stressor. In response to that letter, the Veteran submitted a statement from his sister, attesting to his parents' worry about his non-responsiveness during service and calls she made to Fort Benning and the Red Cross. In addition, the Veteran submitted a photograph in which he was standing with his parents while in uniform. In March 2015 correspondence, the Veteran's attorney asserted that the photograph shows the Veteran wearing a Combat Infantryman Badge, an Army Airborne patch, and a Parachute Badge. In October 2015, the Veteran submitted a more specific statement describing the in-service experiences he asserted caused his current psychiatric disorder. He reported beginning his time in service in the Airborne Ranger Elite Unit. He stated that in December 1970, he was asked to join the Black Ops division as a sniper, under the direct command of the Central Intelligence Agency (CIA). He stated he was deployed to Vietnam where he was stationed until March 1972. He stated that he saw dismembered bodies everywhere he went and explained that he had to see heads blow up over and over due to the nature of his duties as a sniper. The Veteran further stated that he worked with a very small group of people and was never given names of locations, people, or towns, but, rather, was given coordinates. He reported being told to never divulge any information related to his service. In addition to the evidence the Veteran has submitted directly in support of this claim, other evidence of record is relevant to his reported in-service experiences in Vietnam. In that regard, the record documents the Veteran's description of in-service stressors to various parties as early as 2012. For example, during VA treatment in February 2012, the Veteran reported that he was deployed to Vietnam for one year during service, that he served as a sniper, that he killed six enemy soldiers, and that he was stabbed in the right side in the process. The Veteran stated he was treated at a small facility in the middle of nowhere, so he did not believe it had been recorded. In a March 2012 records release authorization form submitted to a congressman, the Veteran reported that he was approached by a CIA operative after basic training and asked to join an elite force. He reported that he trained for six months and then proceeded to Vietnam with the CIA, a colonel, and a team of about six to eight trained soldiers. He stated this group performed top secret missions, that he was promoted to E-5 in the field, was wounded, and saved a platoon at one point by putting down about 22 enemy soldiers. The Veteran reported that he was going to be put in for a Purple Heart and a Silver Star but subsequently discovered that this had never occurred. In a June 2013 letter submitted by the Veteran's Vet Center Readjustment Counseling Therapist, the therapist reported that the Veteran indicated he served as an Airborne Ranger/sniper in Vietnam from 1970 to 1972. During an unrelated VA examination in August 2013, the Veteran reported serving as an Airborne Ranger/sniper in Vietnam for 14 months beginning in 1970. In addition to the foregoing descriptions provided by the Veteran, evidence included in his service treatment and personnel records is relevant. The Veteran's DD-214 lists his military occupational specialty (MOS) as a petroleum storage specialist and reflects that he was an E-4 at separation. It does not document any overseas service. Despite reflecting a National Defense Service Medal, Parachute Badge, Drivers Badge, and M-16 Sharpshooter Badge, it does not document any type of combat service or combat badges that would be awarded to soldiers who served in the Republic of Vietnam. In August 2013, a request was placed with the Joint Services Records Research Center (JSRRC), which reviewed the Veteran's complete military personnel and medical treatment records, as well as any other relevant records pertaining to the Veteran, and concluded that there was not credible evidence that could substantiate the Veteran's claim of service in the Republic of Vietnam. The Veteran's attorney has requested additional development per VA Fast Letter 09-52, concerning the verification of stressors in special operations incidents. The Board does not find that such development is necessary based upon the evidence available at this time. Initially, the Board recognizes that the August 2013 request for stressor development through the JSRRC returned a negative finding based on the Veteran's complete personnel record. More significantly, however, the Board does not find the Veteran's description of in-service experiences in Vietnam credible. The Board notes that the Veteran's own descriptions, detailed above, regarding the length of time he spent in Vietnam, when he first arrived in Vietnam, the timing of his initial contact with the CIA, and the nature of his activities in-country are internally inconsistent. Notably, the Veteran did not describe being stabbed in the right side by an enemy soldieran incident which would be expected to have more verifiable circumstances, if only in the form of verifiable post-injury residuals or scarringin connection with this claim. Even assuming that the Veteran could have had foreign service that was not documented in any manner due to its top-secret nature, both his service treatment records and his service personnel records place him in the United States during the general time periods he has described being deployed to Vietnam. For example, his personnel records indicate he spent the period in question assigned to Ft. Bragg in North Carolina, where he worked as a petroleum storage specialist. In January, February and April 1971, he was treated at Ft. Bragg for various dental issues. In August 1971, he was treated for tonsilitis, also at Ft. Bragg. Although the Veteran's reports of the length of his time in Vietnam have varied, they all suggested that he was in-country throughout a large portion of 1971. With respect to the submitted photograph, the Board notes that the Veteran's service personnel record indicates that he was assigned to the 582d Supply Company of the 82d Airborne Division, at Ft. Bragg, North Carolina service which would account for his wearing the badge in question while stationed in the United States. While the Veteran also asserts that the photograph shows a Combat Infantryman Badge, the Veteran's personnel record does not document that he was ever issued that badge, and, as explained above, the Veteran's reports of the nature and timing of his combat service are both internally inconsistent and contradicted by service treatment records documenting that he was in the United States during the time he has reported serving in Vietnam. In other words, in spite of the existence of this photograph, the weight of the evidence addressing the question of the Veteran's combat service in Vietnam is against his claim. The Board acknowledges that the Veteran has not been afforded a VA examination in connection with his psychiatric claim. VA's duty to assist only requires it to provide an examination in situations where the evidence shows symptoms of a present disability, an in-service incident or illness to which that present disability may be etiologically linked, and a suggestion that the present symptoms or diagnosis may be linked to the in-service incident or illness. 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the evidence is against finding that the Veteran suffered an in-service incident or illness, to include his stressor as reported. As such, VA's duty to assist does not require it to provide an examination. Finally, the Board acknowledges that it appears additional Vet Center records may be outstanding. However, given the credibility finding explained above, remanding this claim for obtention of those records is unwarranted, as their potential contents could not resolve the significant inconsistencies already present in the evidence of record, particularly the Veteran's documented treatment at Fort Bragg during a period when he has asserted being in-country in Vietnam. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (remand is unnecessary where it "would result in this Court's unnecessarily imposing additional burdens on the [Board and the Secretary] with no benefit flowing to the Veteran."). In summary, the Veteran has not established a continuity of symptoms from the time of service, nor has he established any link between a psychiatric disability and any credibly reported incident of active service. Therefore, the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 2. Entitlement to service connection for hypertension 3. Entitlement to service connection for obstructive sleep apnea 4. Entitlement to service connection for a migraine headache disorder The Veteran also seeks service connection for hypertension, sleep apnea, and a migraine headache disorder. The Board finds that the claims must be denied. As an initial matter, the Board recognizes present diagnoses of hypertension, sleep apnea, and migraine headaches, as documented by a statement from a private treatment provider indicating recent treatment for those disabilities. However, the Board does not find that the Veteran sustained an in-service incident, illness or injury to which his present disabilities may be etiologically linked. A review of the Veteran's service treatment records does not reveal any incidents of elevated blood pressure throughout service or any diagnosis of hypertension during service. Upon separation from service, he showed blood pressure readings of 112 systolic and 72 diastolic, which are lower than that which would be considered hypertensive. There is no evidence in the record of any form of elevated blood pressure or hypertension until many years after separation from service. Neither is there any evidence of sleep apnea or other sleep-related symptoms during active service. He did not complain of headaches or migraines, or any other related symptoms during service, despite seeking treatment for other complaints. Upon separation, he was found to be in good health without any major complaints. To the extent that the Veteran may assert that his claimed conditions are related to herbicide exposure during service in the Republic of Vietnam, as discussed above, the Board finds that the Veteran did not serve in-country in the Republic of Vietnam. He has not asserted exposure to herbicides in any other capacity. As service in the Republic of Vietnam is not found, a presumption of herbicide exposure is not established, and it cannot serve as an in-service incident, illness or injury for purposes of service connection. The Board notes that the Veteran has not been afforded a VA examination in connection with these claims. As the Veteran has not been found to have an in-service incident, illness or injury, VA's duty to assist does not require it provide an examination in these matters. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board does acknowledge statements from the Veteran's private treatment provider indicating that he is treating the Veteran for hypertension and migraine headaches since approximately 2001 around 28 years after separation from active service. However, that statement does not provide any type of etiological conclusion or opinion as to the cause of the Veteran's hypertension or migraine headaches. Rather, it merely confirms a present diagnosis or treatment for those conditions. It does not give a date of diagnosis prior to 2001, and there is no evidence in the record of hypertension, sleep apnea, or migraine headaches prior to that date. The Veteran has not explicitly argued that his claimed conditions began during active service, but the Board does acknowledge his firmly held belief, represented by his filing of this appeal, that his claimed disabilities are related to service. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his conditions, especially in light of the fact that the evidence fails to demonstrate the onset of any related symptoms or diagnoses in service or for many years thereafter. See id. In sum, while the Veteran has present diagnoses, there is no evidence of any in-service incident, illness or injury to which the present disabilities may be etiologically linked. There is no evidence of symptoms from the time of service. There is no evidence linking the present disabilities to any incident of active service. As such, the claims must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claims, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 5. Entitlement to service connection of diabetes mellitus, type II 6. Entitlement to service connection of right upper extremity peripheral neuropathy, diagnosed as diabetic neuropathy 7. Entitlement to service connection of left upper extremity peripheral neuropathy, diagnosed as diabetic neuropathy 8. Entitlement to service connection of right lower extremity peripheral neuropathy, diagnosed as diabetic neuropathy 9. Entitlement to service connection of left lower extremity peripheral neuropathy, diagnosed as diabetic neuropathy The Veteran seeks service connection of diabetes mellitus, type II, and bilateral upper and lower extremity peripheral neuropathy, diagnosed as diabetic neuropathy. The Board finds that these claims must also be denied. Initially, the Board recognizes a present diagnosis of diabetes mellitus, type II, as well as diabetic neuropathy of the upper and lower extremities. As such, the first element of service connection, a presently diagnosed disability, is met. However, the Board does not find that the Veteran suffered an in-service incident, illness or injury to which any of those diagnoses may be etiologically linked. First, the Board recognizes that diabetes mellitus is a presumptive condition secondary to herbicide exposure. However, as addressed in more detail, above, the Board has found that the Veteran did not serve in the Republic of Vietnam, nor has he asserted that he served in any other locations or capacities where he might have been exposed to herbicides. As such, herbicide exposure is not established and presumptive service connection secondary to such exposure is not supported in this matter. A review of the Veteran's service treatment records do not document any symptoms or diagnosis of diabetes or fluctuating or unstable blood sugar. Neither is there any evidence during service of any symptoms of neuropathy. There is no evidence in the record of any such diagnosis during service. There is no evidence in the record of any such diagnosis or symptoms of any of the claimed conditions for many years after active service. The Board notes that the Veteran has not been afforded a VA examination in connection with these claims. As the Veteran has not been found to have an in-service incident, illness or injury, VA's duty to assist does not require it provide an examination in these matters. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board does acknowledge statements from the Veteran's private treatment provider indicating that he is treating the Veteran for diabetes mellitus and diabetic neuropathy since approximately 2001. However, that statement does not provide any type of etiological conclusion or opinion as to the cause of the Veteran's diabetes or diabetic neuropathy. Rather, it merely confirms a present diagnosis or treatment for those conditions. It does not give a date of diagnosis prior to 2001, and there is no evidence in the record of diabetes mellitus or diabetic neuropathy prior to that date. The Veteran has not explicitly argued that these claimed conditions began during active service, either, but the Board again acknowledges his firmly held belief, represented by his filing of this appeal, that these disabilities are related to service. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his diabetes and associated diabetic neuropathy, especially in light of the fact that the evidence fails to demonstrate the onset of any related symptoms or diagnoses for many years after service. See id. Finally, to the extent that the evidence does suggest the Veteran's diabetic neuropathy is directly caused by his diabetes mellitus, because the evidence does not support service connection for diabetes on either a direct or presumptive basis, secondary service connection for diabetic neuropathy is also not supported. In sum, while the Veteran does have present diagnoses of diabetes mellitus, type II, and associated diabetic neuropathy, he was not exposed to herbicides during active service, nor were those conditions manifested to a compensable degree during service or for many years thereafter. As such, presumptive service connection is not supported. He did not sustain any other incident, illness or injury during service to which the presently diagnosed conditions may be etiologically linked. There is no medical evidence linking the present diagnoses to any incident of active service. As such, the claims must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claims, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. Effective Date Generally, except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The effective date of an original award of direct service connection is the day following separation from active service or date entitlement arose if the claim is received within one year after separation from service; otherwise, it is the date of receipt of claim, or date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(b)(2)(i). 10. Entitlement to an effective date prior to December 27, 2011, for the grant of service connection of tinnitus 11. Entitlement to an effective date prior to December 27, 2011, for the grant of service connection of bilateral hearing loss The Veteran has appealed the effective dates assigned for the grants of service connection for tinnitus and bilateral hearing loss. The Board finds that earlier effective dates are not warranted and the claims must be denied. The Veteran filed a claim of service connection for, among other things, hearing loss and tinnitus on December 27, 2011. Prior to that date, the most recent contact with the Veteran occurred on December 24, 1986. All of his prior claims and correspondence with VA involved educational or dependent claims, or financial overpayments. There is no indication in the record prior to December 27, 2011, that the Veteran ever sought to claim service connection of either bilateral hearing loss or tinnitus. As such, the earliest effective date available for the granted claims of hearing loss and tinnitus is December 27, 2011, and the claims for earlier effective dates must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the Veteran's tinnitus, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, "[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7. 12. Entitlement to an initial rating in excess of 10 percent for service-connected tinnitus The Veteran has requested an increased initial rating for his service-connected tinnitus, which is currently assigned a 10 percent rating under 38 C.F.R. § 4.87, Diagnostic Code 6260. Under that diagnostic code, a single 10 percent rating is assigned for tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. The maximum schedular rating available for tinnitus is 10 percent. 38 U.S.C. § 1155; 38 C.F.R. § 4.87; Smith v. Nicholson, 451 F.3d. 1344 (Fed. Cir. 2006). As there is no legal basis upon which to award a higher schedular rating, or separate schedular ratings for each ear, the appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). The Board further finds that referral for consideration of an extraschedular rating is not warranted, as the evidence regarding the Veteran's tinnitus does not show an exceptional disability picture that would render the available schedular rating inadequate. Thun v. Peake, 22 Vet. App. 111 (2008). The Veteran has not provided any evidence that his tinnitus is of such a degree that the 10 percent schedular disability rating is insufficient. In that regard, upon review of the Veteran's claims file, the Veteran has described his tinnitus as "high whistling," steady noise that never stops. Such symptoms are precisely the type of symptoms anticipated by the rating criteria. Beyond ringing in the Veteran's ears, there is no evidence to imply that his tinnitus symptoms are not addressed by the rating criteria. He has not complained of any other neurological or cognitive symptoms that could feasibly be seen in tinnitus. In short, there is no evidence to support a finding that the Veteran's tinnitus symptoms are not addressed by the rating criteria or that his tinnitus has resulted in an exceptional or unusual disability picture. The evidence does not show frequent hospitalization or marked interference with employment as a result of tinnitus. Therefore, the Board finds that the schedular rating of 10 percent for the Veteran's tinnitus is adequate, and no referral is required for extraschedular consideration. 38 C.F.R. § 3.321(b). REASONS FOR REMAND 13. Entitlement to an initial rating in excess of 10 percent for service-connected bilateral hearing loss The Veteran's hearing loss was most recently evaluated in August 2013, over eight years ago. While the mere passage of time is not necessarily adequate grounds upon which to order a new examination, the Board finds that the resulting examination report is not adequate to fully adjudicate the claim. Specifically, while that examination included puretone threshold testing, it failed to provide word discrimination testing scores. While the examiner checked a box indicating that such scores were "not appropriate for this Veteran because of language difficulties, cognitive problems, inconsistent speech discrimination scores, etc.," the examiner failed to specify why such scores could not be provided or were inappropriate. As such, on remand, a new audiometric examination should be conducted which fully assesses the Veteran's bilateral hearing loss. If the examiner cannot complete speech discrimination score testing, then a full explanation for why this is the case should be provided. (Continued on the next page) The appeal is remanded for the following development: Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral hearing loss. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. Specifically, the examiner should conduct puretone threshold testing and Maryland CNC word recognition testing. If the examiner cannot conduct either of the specific requested tests, a complete explanation for why that is the case must be provided. L. STEPANICK Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Pryce, 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.