Citation Nr: 21071634 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 14-40 947A DATE: December 1, 2021 ORDER Entitlement to service connection for diabetes mellitus, to include as due to herbicide exposure is granted. Entitlement to a rating in excess of 40 percent for a low back disability is denied. REMANDED Entitlement to service connection for neuropathy, to include as due to herbicide exposure is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for right ear hearing loss is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's diabetes mellitus is due to hs exposure to herbicides. 2. The Veteran's low back disability does not exhibit ankylosis. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for diabetes mellitus, to include as due to herbicide exposure have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 2. The criteria for entitlement to a rating in excess of 40 percent for a low back disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5243. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1968 to October 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2012 and September 2012 rating decisions by the Department of Veterans Affairs (VA). In August 2017, the Veteran testified at a Board hearing. The transcript of that hearing has been associated with the Veteran's claims file. In November 2018, the case came before the Board. The Board found that new and material evidence had been submitted to reopen the Veteran's claim for entitlement to service connection for PTSD. In turn, the Board remanded this issue for an additional VA examination. In addition, the Board remanded the Veteran's claims for entitlement to service connection for diabetes, neuropathy, and a major depressive disorder in order for the RO to obtain the Veteran's Social Security Administration disability records and his medical treatment records. Moreover, the Board remanded the Veteran's claim for service connection for right ear hearing loss in order to clarify whether the Veteran wanted to withdraw that claim. Furthermore, the Board remanded the Veteran's claim for an increased rating for a lumbar spine disability in order for the Veteran to attend an additional VA examination because the evidence of record appeared that the Veteran's disability may have worsened since his last examination. Lastly, the Board remanded the issue of TDIU because it was inextricably intertwined with the issues on appeal. In August 2020, the RO issued a rating decision that granted entitlement to service connection for PTSD with major depressive disorder. Thus, these issues are no longer before the Board. This is further demonstrated by the fact that the representative did not object to the lack of any further mention of the issue of entitlement to service connection for a psychiatric disability other than PTSD in his September 2020 response to the August 2020 supplemental statement of the case. 1. Entitlement to service connection for diabetes mellitus, to include as due to herbicide exposure The Veteran contends that his diabetes is due to his exposure to herbicides. The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). Other specifically enumerated disorders will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 C.F.R. §§ 3.309. Service connection may also be granted for certain specified diseases on a presumptive basis if a veteran was exposed to Agent Orange during active service. See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(b), 3.309(e). A Veteran is presumed exposed to Agent Orange if he or she had active military, naval, or air service, in the Republic of Vietnam from January 9, 1962 through May 7, 1975, "unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The Department of Defense has also confirmed to VA that herbicides were used in Thailand during the Vietnam Era. The majority of troops in Thailand during the Vietnam Era were stationed at the Royal Thai Air Force Bases (AFB) of U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang. See M21-1, Part IV, Subpart ii, Chapter 1, Section H.5.b. If a veteran served on one of these air bases as a security policeman, security patrol dog handler, member of a security police squadron, or otherwise served near the air base perimeter, as shown by MOS (military occupational specialty), performance evaluations, or other credible evidence, then herbicide exposure should be acknowledged on a facts-found or direct basis. Id. This applies only during the Vietnam Era. Id. The availability of presumptive service connection for a disability based on exposure to herbicides, however, does not preclude a veteran from establishing service connection with proof of direct causation. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The list of diseases associated with exposure to certain herbicide agents is as follows: AL amyloidosis, chloracne or other acneform disease consistent with chloracne, type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309 (e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, some medical issues fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale and a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the Veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau, supra. Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Lastly, in order to deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). As to a current diagnosis, the Board notes that the Veteran's disability has been diagnosed as diabetes mellitus type II. Initially, the Board notes that the Veteran's military personnel records demonstrate that the Veteran was an aircraft maintenance mechanic and he was assigned a tour of duty in Thailand. As to the Veteran's lay statements, the Board notes that the Veteran testified that his barracks were close to the base perimeter. In addition, the Board notes that the Veteran testified that his duties on the "flight line" brought him into close proximity to the base perimeter. The Board finds the Veteran's testimony to be highly probative. Accordingly, the Board has placed significant weight on his statements because he provided highly detailed and specific accounts of his experiences in Thailand that brought him in close proximity to the base perimeter. In sum, the Board finds that service connection for diabetes mellitus type II is warranted. After a review of the record, the Board finds that the most probative evidence of record is the Veteran's testimony and his service personnel records which demonstrate that the Veteran was likely exposed to herbicide agents to include Agent Orange during service in accordance with his duties near the base perimeter in Thailand. Thus, based on the foregoing, and resolving reasonable doubt in the Veteran's favor, the Board finds that service connection is presumptively warranted for the Veteran's diabetes mellitus type II. This determination is limited to this specific Veteran, based on the facts presented. 2. Entitlement to a rating in excess of 40 percent for a low back disability The Veteran contends that his lumbar spine disability warrants an increased rating. A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in such cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Instead, in Mitchell, the Court explained that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, and less or more movement than is considered normal, weakened movement, excess fatigability, and pain on movement (with swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board observes that the words "slight," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in the process of arriving at a decision regarding an increased rating. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. VA received the Veteran's claim for an increased rating on June 24, 2011. The Veteran's disability is rated as 40 percent disabling according to Diagnostic Code 5010-5237. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. The additional code is shown after the hyphen. Diagnostic Code 5010 provides that arthritis due to trauma that is substantiated by X-ray findings is to be rated as degenerative arthritis. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted if forward flexion of the thoracolumbar spine is greater than 60 degrees, but not greater than 85 degrees; the combined range of motion of the thoracolumbar spine is greater than 120 degrees, but not greater than 235 degrees; there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or there is vertebral body fracture with loss of 50 percent or more of the height, a 20 percent rating is warranted for forward flexion of the lumbar spine greater than 30 degrees but less than 60 degrees, or combined range of motion of the lumbar spine not greater than 120 degrees, or muscle spasm, guarding or localized tenderness resulting in abnormal gait or an abnormal spinal contour. A 40 percent rating is warranted for forward flexion of the lumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent, the maximum available, is warranted for unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a. These ratings are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Id. Note (2) of the General Rating Formula provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, DC 5243. Note (5) to the General Rating Formula for Diseases and Injuries of the Spine provides that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a Diagnostic Code 5243 provides that intervertebral disc syndrome (IVDS) is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on incapacitating episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating IVDS based on incapacitating episodes provides a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent disability rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent disability rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. Note (1) to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. As to a current diagnosis, the Board notes that the Veteran's disability has been diagnosed as low back strain with degenerative joint arthritis. As to the Veteran's lay statements, the Board notes that the Veteran testified that he experiences severe back pain with pain shooting into his legs. The Veteran also testified that he has trouble with prolonged standing, walking, bending, stooping, and lifting more than 10 pounds from floor. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in August 2011. The Veteran reported experiencing pain and that he has to use a walker. The Veteran reported severe flareups that occur weekly. The Veteran reported that during a flareup, he can't get comfortable and he can't move. The examiner indicated that the Veteran exhibited flexion 0 to 20 degrees, extension 0 to 5 degrees, left lateral flexion 0 to 10 degrees, left lateral rotation 0 to 30 degrees, right lateral flexion 0 to 10 degrees, and right lateral rotation 0 to 30 degrees. The examiner indicated that the Veteran exhibited no lost range of motion after repetitive testing. The examiner indicated that there was no objective evidence of pain on range of motion testing and passive range of motion was unchanged from active range of motion. Lastly, the examiner indicated that the Veteran did not exhibit ankylosis. In May 2012, the Veteran attended an additional VA examination. The Veteran reported pain in his low back and he also reported experiencing flareups. The Veteran stated that flareups are like a "hot knife" in his back. Upon examination, the examiner indicated that the Veteran exhibited flexion to 10 degrees with pain at 10 degrees, extension to 5 degrees with pain at 5 degrees, right lateral flexion to 5 degrees with pain at 5 degrees, left lateral flexion to 5 degrees with pain at 5 degrees, right lateral rotation to 5 degrees with pain at 5 degrees, and left lateral rotation to 5 degrees with pain at 5 degrees. The Veteran was able to perform repetitive use testing with no additional lost range of motion. The examiner also indicated that there were no signs of IVDS or ankylosis. In October 2017, the Veteran attended a private medical examination. The private examiner indicated that the Veteran did not experience ankylosis. The private examiner indicated that the Veteran exhibited pain at less than 30 degrees of forward flexion. The private examiner indicated that the Veteran exhibited pain, swelling, muscles spasms, and tenderness. In July 2019, the Veteran attended a VA examination. The Veteran reported that he avoids heavy lifting/carrying, prolonged walking/standing, and bending/twisting as this may cause flareups. The Veteran did not report any flareups. Upon examination, the examiner indicated that the Veteran exhibited forward flexion 0 to 45 degrees, extension 0 to 10 degrees, right lateral flexion 0 to 20 degrees, left lateral flexion 0 to 20 degrees, right lateral rotation 0 to 20 degrees, and left lateral rotation 0 to 20 degrees. The examiner indicated that the Veteran was able to perform repetitive testing with no additional lost range of motion. The examiner stated that although the Veteran subjectively notes decrease in range of motion during a flare or repetitive use over time the record review fails to provide objective evidence to support this claim. Lastly, the Board notes that the examiner indicated that the Veteran does not exhibit ankylosis or IVDS. The Board further notes that with respect to the Veteran's testimony regarding shooting pains into his legs, a claim for service connection for degenerative disc changes at L3-4 with radiating pain into the legs was previously denied by the RO, and therefore may not be considered at this time for rating purposes in conjunction with the Veteran's increased rating claim for his service-connected low back condition. The Board has also reviewed the Veteran's medical treatment records and notes that the Veteran's records do not show signs or symptoms of IVDS or ankylosis. In sum, the Board finds that the Veterans' disability has remained consistent and that a rating increase is not warranted. The Board has considered a rating in excess of 40 percent; however, the record does not contain any evidence that the Veteran's spine exhibits signs or symptoms of ankylosis. Moreover, the record does not show that the Veteran's disability exhibited incapacitating episodes that required physician ordered bed rest. The Board has also considered the Veteran's reports of pain on movement and reduced movement during a flareup; however, the medical evidence of record does not show that the Veteran's pain on movement resulted in the development of ankylosis. In addition, as was noted above, with respect to the Veteran's testimony regarding shooting pains into his legs, a claim for service connection for degenerative disc changes at L3-4 with radiating pain into the legs was previously denied by the RO, and therefore may not be considered at this time for rating purposes in conjunction with the Veteran's increased rating claim for his service-connected low back condition. Accordingly, for all of the above stated reasons, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim for entitlement to a rating in excess of 40 percent for his lumbar spine disability, must be denied. REASONS FOR REMAND 1. Entitlement to service connection for neuropathy, to include as due to herbicide exposure is remanded. As to the Veteran's claim for service connection neuropathy, the Board notes that the Veteran has not been afforded a VA examination for this disability. According to McLendon, an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in- service event, injury, or disease," or that a disease, manifested in accordance with presumptive service connection regulations, occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Board notes that the Veteran has reported pain in his legs and has been diagnosed with neuropathy. The Board further notes that the Veteran has attributed this disorder to his exposure to herbicides while on active duty. Moreover, the Board notes that there is an indication that the current disability may be related to his military service or his newly service-connected diabetes, and there is insufficient evidence to decide this case. As the Board finds that the criteria set forth in McLendon has been met to this claim, a VA examination should be obtained. 2. Entitlement to service connection for erectile dysfunction is remanded. As to the Veteran's claim for service connection for erectile dysfunction, the Board notes that the Veteran has also not been afforded a VA examination for this disability. In this case, the Board notes that the Veteran has been diagnosed with erectile dysfunction and he has attributed this disability to his service-connected low back disability. The Board further notes that there is an indication that this disorder may be related to his service-connected disabilities, and there is insufficient evidence to decide this case. As the Board finds that the criteria set forth in McLendon has been met to this claim, a VA examination should be obtained. 3. Entitlement to service connection for right ear hearing loss is remanded. In November 2018, the Board was unsure as to whether the Veteran fully understood that he was withdrawing any further consideration of this claim. Accordingly, the Board requested the RO to contact the Veteran's representative to provide a written withdrawal of the claim for service connection for right ear hearing loss. The Board further instructed the RO to inform the Veteran's representative that if such a written withdrawal is not received, the claim will continue to be considered in appellate status. A review of the record indicates that the RO did not carry out the Board's instruction and the Veteran did not formally withdraw this claim in writing. Therefore, the Board finds that this issue is still on appeal. The Board notes that the Veteran attended a VA examination for this issue in May 2012. Following the examination, the examiner stated that the test results that were recorded at the examination were unreliable and unsuitable for rating purposes, but the examiner still found that that the Veteran's disability was less likely as not due to his military service. The Board finds this opinion to be inadequate to decide this case because the examiner did not provide a thorough and well-reasoned opinion that addressed the noise that the Veteran was exposed to while on active duty. Thus, the Board finds that a remand is required to obtain a more complete medical opinion as to the nature and etiology of the Veteran's disability. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.310; Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); Bloom v. West, 13 Vet. App. 185, 187 (1999) (a medical opinion without supporting clinical data or other rationale does not provide the required degree of medical certainty). 4. Entitlement to a total disability rating due to individual unemployability (TDIU) The Veteran's claim for TDIU is intertwined with the issues currently on appeal. Harris v. Derwinski, 1 Vet. App. 180 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together). Therefore, further consideration of the claim for TDIU must be deferred. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records from June 16, 2020, to the present. 2. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's neuropathy. The electronic claims file must be reviewed by the examiner. All indicated testing and studies must be conducted, and all pertinent symptomatology must be reported in detail. (A). Is it at least as likely as not (50 percent probability or greater) that the Veteran's neuropathy, had its onset in service or is caused by or related at least in part to his active service? The examiner's opinion should include an analysis pertaining to the Veteran's confirmed exposure to herbicides. (B). Is it as least as likely as not that the Veteran's neuropathy was caused or aggravated by any of the Veteran's service-connected disabilities that now includes diabetes, to include the medications associated with those disabilities? 3. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's erectile dysfunction. The electronic claims file must be reviewed by the examiner. All indicated testing and studies must be conducted, and all pertinent symptomatology must be reported in detail. (A). Is it at least as likely as not (50 percent probability or greater) that the Veteran's erectile dysfunction, had its onset in service or is caused by or related at least in part to his active service? (B). Is it as least as likely as not that the Veteran's erectile dysfunction was caused or aggravated by any of the Veteran's service-connected disabilities that now include diabetes, to include the medications associated with those disabilities? 4. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's right ear hearing loss. The electronic claims file must be reviewed by the examiner. All indicated testing and studies must be conducted, and all pertinent symptomatology must be reported in detail. Is it at least as likely as not (50 percent probability or greater) that the Veteran's right ear hearing loss, had its onset in service or is caused by or related at least in part to his active service? The examiner's opinion must include a complete rationale for all opinions expressed. In providing all of the requested opinions, the examiner should consider the Veteran's competent lay claims regarding the observable symptoms he has experienced. 5. Take all additional steps necessary to adjudicate the Veteran's claim for TDIU. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Rescan, 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.